Columbia  tEbtittntfftp 

tntljfCitpofilrttjgork 

THE  LIBRARIES 


iflebical  Htbrarp 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/chronicdisordersOOvanv 


The  Chronic  Disorders 


of  Tin: 


Digestive  Tube 


BY 


W.  W.  VA~N  VALZAH,  A.M.,  M.D. 

Formerly  Demonstrator  of  Clinical  Medicine, 
Jefferson  Medical  College 


New   Vork 

J.   H.  VAIL  ,t   CO. 

1893 


I 


\ 


<  '.il'YRlCHT    HV 

W.    W.  VAN    VAI./AH,  M.D. 


nisi  or 

NEK,   Ll»««  *  CO. 
r«  *  f<.    RE»DE  ST., 
HEW  YORK. 


PREFACE. 


This  little  book,  with  the  exception  of  the  chap- 
ter on  habitual  constipation,  is  made  up  of  com- 
munications during  the  past  year  to  the  Journal  of 
the  American  Medical  Association,  the  New  York 
Medical  Journal,  and  the  Medical  Record.  I  have 
been  persuaded  to  combine  and  reprint  tin  sse  articles 
under  one  cover,  in  order  to  present  to  the  profes- 
sion, in  an  easily  accessible  form,  a  short  and 
practical  study  of  the  chronic  disorders  of  the  ali- 
mentary tract.  Originally  intended  for  serial  pub- 
lication, no  very  great  changes  haA'e  been  found 
necessary  to  adapt  them  to  the  present  form. 

Great  pains  have  been  taken  to  make  each  chap- 
ter complete  in  itself.  This  plan  has  both  its 
advantages  and  disadvantages.  It  relieves  the  busy 
reader  of  the  necessity  of  going  through  the  book 
in  order  to  find  the  author's  treatment  of  a  particu- 
lar disorder;  but  it  also  renders  it  impossible  to 
avoid  repetition  of  certain  basic  and  controlling 
principles.  The  importance  (in  the  opinion  of  the 
writer)  of  these  principles  is  a  satisfactory  explana- 
tion and  apology  for  their  frequent  statement. 


Y 

'& 


iv  PREFACE. 

Popular  opinion  places  seasickness  among  the 
disorders  of  the  stomach.  This  contention  is  shown 
to  be  erroneous,  and  an  attempt  is  made  to  explain 
the  nature  of  this  neglected  disease.  A  justification 
for  iis  consideration  under  this  title  maybe  found 
in  the  fact  that  to  secure  healthy  digestion  and 
motility  before  and  during  the  voyage  is  the  besl 
way  to  prevent  the  gastro-intestinal  disturbances 
secondary  to  this  peculiar  sensory  form  of  vertigo. 

No.  i"  East  Forty-third  Street, 

New  York,  December  1-1.  1892. 


CONTENTS. 


CHAPTER  I. 
General  Therapeutic  Considerations,         ...      1 

CHAPTER   II. 
The  Chronic  Disorders  of  Gastric  Digestion,  .        .     13 

CHAPTER  III. 
A  Clinical  Study  of  Intestinal  Indigestion,     .        .    4(5 

CHAPTER  IV. 

The   Causation   and  Treatment    of   Chronic    Diar- 
rhoea,     sl> 

CHAPTER  V. 
The  Curative  Treatment  of  Habitual  Constipation.   102 

APPENDIX. 

I.  A  Clinical  Paper  on  the  Treatment    of    Func- 

tional and  Catarrhal  Diseases  of  the  Stomach 
and  Bowels, 113 

II.  The  Nature  and  Preventive  Treatment  of  Sea- 

sickness,            ....  132 


THE 


CITRO'NTr     DISORDERS 


DIGESTIVE     TUBE. 


CHAPTER  I. 

GENERAL   THERAPEUTIC   CONSIDERATIONS. 

The  results  of  the  surgical  treatment  of  disease 
are  palpable  and  often  brilliant.  The  wonderful 
achievements  and  rapid  advances  of  modern  sur- 
gery are  manifest,  and  its  results  can  be  built  up 
into  statistics  that  will  not  yield  to  scepticism's 
destroying  touch.  It  is  not  so  in  medicine.  Our 
great  triumphs  are  in  the  prevention  and  control 
as  well  as  in  the  cure  of  disease,  and  the  entire 
good  that  we  do  cannot  be  known.  The  surgeon 
believes  in  the  knife  because  he  sees  its  power, 
recognizes  its  limitations,  brings  other  powerful 
means  to  its  aid,  and  proceeds,  in  a  way  often 
clearly  marked  out  in  every  detail,  to  the  accom- 
plishment of  a  definite  purpose.  The  physician's 
l 


•„'.  GENERAL   THERAPEUTIC    CONSIDERATIONS. 

scepticism  is  born  of  the  obscurit)'  of  therapeutic 
results,  faulty  and  narrow  methods,  and  a  failure 
to  recognize  the  limitations  imposed,  by*  the  nature 
and  stage  of  the  morbid  process.  I'>ui  we  do  more 
than  we  know,  or  are  able  to  explain.  We  are 
powerless  at  the  bedside  only  when  therapeutic  ni- 
hilism has  boldly  swept  away  every  landmark  and 
light,  [n  the  hour  of  transcendenl  need  the  physi 
cian,  standing  in  the  dim  twilight,  bends  forward 
into  the  darkness  to  cure,  to  strengthen,  and  to 
bless. 

In  the  chronic  disorders  of  the  digestive  tube 
scepticism  finds  an  almost  impregnable  stronghold, 
well  barricaded  by  professional  and  popular  opinion 
againsl  successful  assault.  These  troubles  rarely 
disappear  in  the  course  of  nature,  for  they  pO£ 
an  inherent  power  of  self-perpetuation,  and  many 
physicians  seem  to  have  a  little  too  much  faith 
in  the  unaided  power  of  drugs.  These  invalids 
too  frequently  fail  to  get  the  slightest  benefit  from 
the  few  magical  prescriptions  of  even  the  best  and 
greatest  men  of  our  profession,  and  turn  to  folk- 
lore for  relief,  and  a  little  later  a  few  more  victims 
are  added  to  the  list  of  the  consumers  of  the  many 
patent  medicines  "good  for  digestion  and  the  liver, 
and  diarrhoea  and  constipation."  And  thus  oui 
profession  falls  into  disrepute.  It  might  be  well  to 
prescribe  a  little  less  medicine,  and  he  a  little  more 
explicit  and  full  and  emphatic  in  orders  concern 
ing  hygiene  and  dietetics.  Drugs,  by  affording  an 
excuse  for  the  neglect  of  other  more  powerful  n-u)t- 
dies,  too  often  become  the  world's  grave-diggers; 
and  this  little  book  Bhall  not  accomplish  its  purpose 


GENERAL   THERAPEUTIC    OONSIDKRATIONS.  » 

if  it  fails  !•'  establish  the  essential  utility  of  rigid 
living  and  a  proper  diet  in  the  treatmenl  of  the 
chronic  disorders  of  digesl  ion  and  nutrition.  Medi- 
cal practice  knows  no  more  brilliant  results  than 
those  obtained  by  the  right  management  of  these 
diseases.  But  the  treatment  must  be  well  defined, 
comprehensive,  and  thoroughly  and  systematically 
carried  out.  It  may  bo  well  to  go  into  detail  and 
define  the  basis,  purpose,  and  some  of  the  necessary 
limitations  of  the  therapeutics  of  these  chronic  dis- 
orders of  the  alimentary  canal. 

Disease  is  in  its  primitive  nature  a  perversion 
of  force  which  determines  the  fixed  pathological 
changes  and  often  dominates  the  symptomatic  ex- 
pression. This  fundamental  truth  must  be  recog- 
nized before  therapeutics  can  claim  to  be  a  science 
rather  than  an  art  based  on  the  contradictory  testi- 
mony of  experience.  Curative  therapeutics  must 
go  beyond  the  symptoms  and  morbid  tissue  changes 
to  the  disturbance  of  the  normal  relations  that  cells, 
or  aggregate  of  cells,  or  the  organism,  bear  to  their 
environment.  It  must  not  be  directed  solely  against 
the  symptom  group,  nor  be  controlled  by  the  mor- 
bid anatomy  alone,  nor  find  its  only  guide  in  the 
perversion  of  the  physiological  processes.  The 
chronic  disorders  of  digestion  and  nutrition  are,  in 
their  incipiency,  the  expression  of  either  a  chemical 
lesion  of  the  fluid  in  which  the  cell  lives,  or  a  nutri- 
tive defect  in  the  structure  and  composition  of  the 
cellular  protoplasm.  It  is  the  alterations  of  tbe 
composition  of  the  fluids  of  the  body,  and  the  con- 
sequent indefinable  defect  in  the  structure  of  the 
cellular  protoplasm  so  intimately  related  to  the  un- 


I  GENERAL   THERAPEUTIC   CONSIDERATIONS. 

healthy  variations  in  the  functions  of  the  cell,  which 
make  up  the  canvas  <>n  which  the  clinical  picture  is 
painted  in  the  colors  of  morbid  anatomy.  Tt  is  the 
faulty  assimilation  of  imperfectly  prepared  nutrient 
material,  as  embodied  in  a  badly  constituted  proto- 
plasm, thai  gives  the  progressive  quality  to  these  dis- 
orders, and  the  one  hope  6f  relief  and  the  -rand  pur 
pose  of  treatment  is  to  secure  in  some  way  a  better 
quality  of  cellular  content s;  to  corrert  tl lis  nutritive 
defect.  This  cannot  he  done  by  starvation  any  more 
than  it  can  he  accomplished  hy  forced  feeding.  It 
is  the  combination  of  means  that  will  remove  as 
well  as  build  up,  that  break  down  as  well  as  regene- 
rate, which  will  yield  a  permanent  result.  An  ex- 
t  reme  nicety  of  the  digestion  and  of  the  preparation 
of  the  nutrient  material,  its  proper  distribution  to 
the  tissues  by  the  blood,  the  quick  solution  and  re- 
moval of  waste  products,  and  the  conservation  of 
nerve  force,  place  the  cell  in  an  environment  which 
is  most  favorable  to  its  nutrition  and  life.  The 
promotion  of  a  high  degree  of  healthy  nutrition  is 
the  one  essential  purpose  ;  and,  in  the  present  state 
of  knowledge,  cell  life  can  be  appreciably  influenced 
or  controlled  only  by  modifying  its  environment. 
A  treatment  based  on  this  principle  is  causative  and 
(inative.  and  scorns  a  plan  that  only  aims  to  secure 
the  suppression  of  symptoms. 

As  we  have  already  seen,  these  chronic  disorder- 
arise  from  the  persistent  and  almost  imperceptible 
disturbance  of  the  continuous  adjustment  of  rela- 
tions as  manifested  in  the  life  processes — the  inte- 
gration of  structure,  the  evolution  of  force,  or  the 
elimination  of  waste   products.     The  diatheses  are 


GENERAL   THERAPEUTIC   CONSIDERATIONS.  5 

■examples  of  these  evil  tendencies  indelibly  stamped 
upon  the  organism  in  the  process  of  its  making, 
and  may  manifest  themselves  directly  or  indirectly, 
through  nerve  or  blood  or  lymph  changes,  as  dis 
orders  of  the  digestive  system  and  its  appended 
glands.  Now  it  is  a  predisposition  to  the  develop- 
ment of  lowly  organized  cells — a  defect  of  nutrition 
in  which  the  power  of  assimilation  is  in  abeyance 
— a  vice  of  constitution  in  which  the  tissues  yield 
readily  to  incident  disturbance  and  have  little  con- 
structive power  ;  of  such  a  nature  is  the  inherited 
nutritive  dyscrasia  which  forms  so  favorable  a  soil 
for  tuberculosis.  Now  it  is  the  fibrous  tissue  which 
shows  the  evil  tendency  and  stamps  the  organism 
with  the  fibroid  diathesis.  Or  it  is  a  hgemic  or  he- 
patic state  that  manifests  itself  as  rheumatism  or 
gout.  Now  it  is  a  fault  of  the  more  highly  evolved 
nerve  centres,  and  the  patient  falls  a  victim  of  some 
neural  disorder  or  is  skilfully  conducted  through 
life  on  a  sleeping  volcano.  Or  it  may  be  some  de- 
fect of  elimination  which  permits  the  accumulation 
of  some  such  waste  product  as  uric  acid  in  the  sys- 
tem. These  evil  tendencies,  when  inherited,  which 
underlie  many  cases  of  disordered  digestion,  can- 
not be  completely  eradicated  by  treatment,  and  our 
purpose  in  therapeutics  is  limited  to  the  prevention 
or  control  of  the  manifestations. 

Again,  the  treatment  of  these  chronic  disorders 
is  limited  by  destruction,  degeneration,  and  atro- 
phy of  the  anatomical  elements,  and  by  deformity. 

In  acute  disease  the  incident  disturbance  falls 
directly  on  the  functionating  cells,  which  recover  or 
redevelop  more  or  less  completely  when  the  morbid 


6  GENERAL  THERAPE1    PIC   CONSIDERATIONS. 

influence  passes  away  ;  or  function  is  perverted  by 
tin-  compression  of  unorganized  inflammatory  pro 
duels.  In  chronic  disease  the  cells  are  sometimes 
involved  indirectly  by  the  formation  of  new  tissue 
and  by  compression.  The  new  connective  tissue 
may  simply  irritate,  but  it  usually  contracts  from 
and  dies  itself  and  destroys  other  neighboring 
tissue.  A  cure  is  possible  only  in  the  formative 
stage,  when  the  chronic  productive  inflammation 
may  resolve.  Therapeutics  is  thus  limited  by  the 
nature,  relations,  and  age  of  the  pathologically 
formed  tissue. 

Chronic  disorders,  again,  often  arise  from  de- 
generation  or  atrophy  or  deformity.  The  persist- 
ence of  the  symptoms  is  clue  to  the  persistence  of 
the  damage  done  by  former  disease.  We  can  do 
nothing  in  a  medical  -way  to  remove  the  cicatricial 
stenosis  of  the  pylorus  or  stricture  of  the  bowel. 
When  chronic  disease  falls  directly  on  the  anal i mi i 
cal  elements  of  an  organ,  it  is  commonly  a  degene- 
rative or  atrophic  process,  and  if  the  cells  be  repro- 
duced they  are  imperfectly  and  lowly  organized. 
When  gastric  atrophy  occurs  from  age,  little  can 
be  done  to  stay  the  progress  of  decay,  for  it  is  usu- 
ally accompanied  by  a  like  condition  of  the  duode- 
num and  of  the  other  viscera  ;  life  slowly  dissolves 
beneath  its  burning  rays.  But  when  atrophy  occurs 
in  the  developmental  or  vigorous  periods  of  life,  as 
in  the  gastric  atrophy  following  typhoid  fever,  or 
the  intestinal  atrophy  resulting  from  prolonged  dis- 
tention by  the  gases  of  organic  fermentation,  treat  - 
nient  is  limited  but  of  some  avail.  An  accurate 
anatomical  diagnosis  defines  and  limits  therapeutics. 


GENERA  L   TIIKi;  A  PEUTI<     ( fONSIDERATIONS. 

Having  briefly  indicated  the  primitive  nature  and 
the  basis  of  the  cure  of  these  chronic  disorders,  and 
advocated  the  necessity  and  the  utility  of  a  well- 
defined  and  comprehensive  treatment,  turn  we  to  a 
consideration  of  the  remedies  to  bo  systematically 
employed. 

Our  therapeutic  purpose  in  chronic  disease  is 
never  so  narrow  as  the  prescription  of  this  or  thai 
drug  ;  it  is  the  combination  of  many  means  to  meet 
complex  indications,  the  treatment  of  the  whole 
man  as  disturbed  by  disease.  As  we  grow  old  and 
gray  in  the  service  of  our  calling,  the  less  do  we 
rely  on  drugs  alone.  By  the  proper  use  of  drugs 
we  can  often  snap  the  thin-spun  thread  of  evil  se- 
quences, and  we  will  not  be  persuaded  to  cast  away 
means  of  such  power  and  precision.  I  believe  our 
object  is  best  accomplished  by  a  systematic  combi- 
nation of  remedies.  And  our  first  aim  should  be  the 
promotion  of  a  high  degree  of  healthy  nutrition 
with  a  view  to  increasing  the  resistance  and  activ- 
ity of  the  tissues  and  to  securing  physiological  cell 
structure  ;  and,  secondly,  the  regulation  of  the  pa- 
tient's life  and  diet  with  a  view  to  the  readjustment 
of  the  damaged  organism  to  vital  demands  ;  and. 
in  the  third  place,  the  rational  use  of  drugs  as  based 
on  their  physiological  actions  and  as  confirmed  by 
clinical  experience.  This  forms  the  great  tripod  of 
treatment. 

If  one  will  take  the  trouble  to  turn  through  medi- 
cal literature  he  will  be  surprised  to  learn  the  con- 
spicuous part  which  has  always  been  assigned  in 
aetiology  to  "  impairment  of  the  general  health."  In 
many  cases  of  acute  disease  the  most  robust  const  i- 


8  GENERAL   THERAPEUTIC   CONSIDERATIONS. 

i  in  ion  yields  to  the  shock  of  the  violent  onset.  It 
is,  however,  more  of  ten  the  weak  and  tired  who  are 
forced  to  the  wall.  But  a  well- nourished  body  not 
only  resists  invasion;  it   also  limits  and  conditions 

and  controls  the  morbid  process— has  a  curative 
power.  A  problem  to  solve  in  all  of  these  chronic 
disorders  is  the  problem  of  nutrition,  and  upon  its 
solution  depends  the  possibility  of  relief.     And  it  is 

n«»l  ci  i.  M  i-l  i  to  adapt  the  quant  it  y  and  quality  of  the 
food  to  the  vice  of  nutrition  we  wish  to  correct  or 
the  state  of  nutrition  we  wish  to  establish,  though 
this  is  oi'  very  great  importance.  It  is  not  enough 
to  adapt  the  quantity  and  quality  of  the  food  to  the 
present  state  of  nutrition,  the  capability  of  the  di- 
gestive organs,  the  activity  of  the  emunctories,  and 
the  evolution  of  force  as  conditioned  by  habits  of 
lite  and  environment— though  if  this  he  nol  don. 
success  will  rarely  crown  our  efforts.  But  the  pa- 
tient must  he  kept  under  daily  supervision,  and  the 
physician  must  see  that  the  diet  is  fulfilling  its  Hum 
apeutic  purpose,  and  readjustments  be  made  to  meet 
the  varying  indications  afforded  by  the  clinical 
guides  to  nutrition  and  digestion.  The  ability  to 
use  one's  knowledge  in  the  treatment  of  disease  Is  a 
distinguishing  mark  of  the  practical  physician.  In 
tin'  chronic  disorders  of  the  digestive  tube  it  is 
sential  to  have  it  made  clear  to  us  how  the  food  is 
being  worked  up  and  utilized  in  each  particular 
case.  This  cannol  be  easily  determined  with  exact 
ness  ;  our  guides  are  not  absolute,  because  our 
knowledge  is  not  complete.  Rut  this  is  no  reason 
why  we  should  not  employ  them  so  far  as  we  know 
t  hem  worthy  of  trust.     I  could  just  as  willingly  and 


GENERAL   THERAPEUTIC   CONSIDKRATI0N8.  V 

easily  dispense  with  physical  examinal  ion  in  1 he  <li;i 
gnosis  and  treatment  of  the  diseases  of  the  heart 
and  lungs,  just  as  well  omit  the  microscopic  and 

chemical  examination  of  the  urine  in  the  diseases  of 
the  kidneys,  as  to  turn  out  the  light  thrown  on  l  tie 
disorders  of  digestion  and  nutrition  by  the  exami 
nation  of  the  stools,  the  urine,  and  the  blood.  We 
know  the  qualities  and  number  of  the  corpuscles  of 
healthy  blood,  and  we  know  the  percentage  of  hae- 
moglobin it  contains  ;  and  by  the  microscope,  hae- 
mocytometer,  and  haemoglobinometer  we  can  tell 
when  a  particular  unhealthy  variation  is  approach- 
ing or  falling  away  from  the  normal  standard — this 
is  the  index  of  assimilation.  In  a  similar  manner 
the  urine  gives  a  good  deal  of  testimony  concerning 
disassimilation,  haemolysis,  and  digestion.  And 
something  about  the  condition  of  the  digestive  tube 
may  be  read  in  the  stools.  When  the  information 
obtained  by  these  persistent  examinations  is  sup- 
plemented by  the  knowledge  gleaned  from  the  sub- 
jective symptoms  and  the  physical  signs,  I  have  not 
found  it  very  difficult  to  arrive  at  pretty  accurate 
conclusions  concerning  the  state  and  efficiency  of 
digestion  and  nutrition.  It  is  one  thing  to  calmly 
preach,  from  an  office  chair,  diet  theories  to  a  pa- 
tient struggling  for  relief  ;  it  is  another  to  stand 
sympathetically  by  his  side  and  see  that  he  digests 
and  assimilates  what  he  eats.  The  diet  must  be 
prescribed  on  comprehensive,  scientific  principles, 
with  a  clear,  well-defined  object  in  view,  and  be 
brought  to  the  test  at  the  bedside  ;  for  the  clinical 
test  is  supreme,  and  educated  common  sense  must 


in  GENERAL   THERAPEUTIC   CONSIDERATIONS, 

couiil  for  something  in  the  dietetic  management  of 
the  chronic  disorders  of  the  digestive  tube. 

It  is  not  enough  to  Bend  the  cells  a  fluid  rich  in 
oxygen  and  in  nutrienl  material,  for  il  must  also  be 
free  from  poisonous  products.  The  circulation  of  a 
puir  and  rich  lymph  must  be  active,  so  thai  there 
be  no  accumulation  of  cellular  waste.  A.ctiveoxi 
dation  is  a  strong  barrier  againsl  auto-infection 
if  the  poison  succeed  in  passing  through  the  liver. 
But  the  one  great  remedy  for  auto-infection  is  free 
elimination  by  the  kidneys,  intestine,  Lungs,  and 
skin.  The  besl  solvent,  the  besl  diluent,  and  the 
besl  diuretic  is  a  plentiful  supply  of  fluid;  and  to 
liquefy  the  bile  and  promote  its  discharge,  to  excite 
normal  peristalsis  and  cleanse  the  alimentary  ca- 
rial,  this  fluid  should  be  taken  hot.  In  the  Ca\ 
endish  Lecture  of  1891  Dr.  T.  Lauder  Brunton 
-peaks  of  the  great  value  of  hot  water  in  the  treat 
ment  of  gout,  rheumatism,  and  hthasmia.  It  is  the 
most  efficient  and  the  safest  eliminating  remedy 
that  we  possess.     The  use  of  cholagogues,  diuretics, 

and  diaphoretics  will  prove  of  some  value.      To  se 

cure  a  high  degree  of  healthy  nutrition  we  need  a 
rich,  actively  circulating,  and  pure  lymph.  Every 
cell  must  have  a  clean  lymph  in  which  to  bathe  and 
from  which  to  draw  its  life  and  strength. 

Second  in  importance  only  to  careful  alimenta 
tion  and  active  ehmination  are  the  control  of  the 
habits  of  life  and  the  selection  of  favorable  sur 
roundings.     Here  the  indications  are  so  special  in 
individual  cases  that  little  can  he  said  in  a  general 
way.  ami  much  must  be  left  to  the  physician's  com 
mon  sense  and  experience.    Under  this  heading  musl 


GENERAL   THBRAPEUTIC   CONSIDERATIONS.  I! 

he  included  many  remedies  the  value  of  which  is  well 
recognized— a  favorable  climate,  pure  air  and  sun 
shine,  bathing,  exercise,  rest,  massage,  electricity, 

a  contented  and  hopeful  mental  state,  etc.  all  con 
tributing  to  the  ease  or  activity  of  the  circulation, 
of  respiration,  and,  briefly,  of  all  the  secretory,  ex 
cretory,  and  nutritive  processes.  Physiological  liv- 
ing is  a  great  remedial  power,  and  we  should- never 
grow  weary  in  the  enforcement  of  healthy  physical, 
mental,  and  moral  habits.  Disease  will  not  become 
less  so  long  as  the  people  through  ignorance  do  not 
take  care  of  life.  Enough  vitality  is  destroyed  in 
riotous  living,  morbid  thinking,  and  useless  and 
often  causeless  worry  to  add  to  human  life  another 
score  of  years.  And  it  is  particularly  this  large 
class  of  neurotics  and  dyspeptics  who  do  not  know 
how  to  live  economically  and  conserve  energy. 
The  physician  must  teach  them  to  do  so  before  he 
can  hope  to  cure  them. 

The  tendency  of  modern  drug  treatment  is  local 
and  special.  In  addition  to  local  antiseptics,  we 
have  also  drugs  that  tend  to  keep  the  fluids  of  the 
system  sweet  and  that  affect  one  or  more  of  the 
functions  of  an  organ  in  a  special  way.  It  may  be 
hoped  that  we  may  some  day  be  able  to  directly 
endow  special  cells  with  particular  powers,  and  the 
fond  hope  is  not  without  some  foundation.  We 
have  no  so  thoroughly  efficient  local  treatment  that 
it  cannot  obtain  some  help  from  constitutional 
measures,  and  we  should  not  forget  the  remedies 
that  aid  nutrition,  regulate  elimination,  and  con- 
trol neuro-muscular  discharges.  Drugs  that  relieve 
gross  symptoms  are  also  of  very  great  temporary 


1\!  GENERAL    THERAPEUTIC   CONSIDERATIONS. 

value,     Pain  is  iii  itself  an  <-\  il  and  must  be  quieted. 
Nervousness  must  be  controlled,     [nsomnia  requires 
a  hypnotic.     Bui    i"  the  aid  of   drugs    mus1    be 
broughl  other  and  more  powerful  means — the  pro 
motion  of  a  high  degree  of  healthy  nutrition,  free 
elimination,  well-ordered  habits  of  life,  and  a  favor 
able  environment.     Here  lie  the  hottest  of  the  hat 
t If  and  the  hope  <>l'  victory. 

In  the  management  of  chronic  disease  tacl  and 
common  sense  are  worth  almosl  as  much  as  medi 
cal  knowledge.  The  course  is  a  long  one  and  tests 
the  endurance  of  the  physician.  Such  is  the  soli 
darity  and  such  arc  the  intimate  relations  of  the 
nutritive  processes  that  an  unhealthy  variation  of 
olio  soon  forces  theothers  to  fall  into  harmony  with 
it  :  consequently  these  disorders  are  not  self  limited, 
hut  progressive.  And  it  requires  as  much  time  to 
re-establish  the  normal  state  as  to  arrest  and  correct 
the  primitive  perversion  of  force.  I  would  empha- 
size the  importance  of  Long-continued  supervision 
and  minute  instructions.  The  physician,  as  doc-- 1  lie 
surgeon,  succeeds  most  often  when  he  is  a  strict 
observer  of  detail,  when  he  knows  and  remem- 
bers and  does  little  things. 

My  plea  is  for  a  broad  and  comprehensive  and 
well-defined  therapeutics  ;  a  plea  for  the  paramount 
importance  of  hygiene  and  dietetics;  a  plea  for  the 
considerate  use  of  drugs;  a  plea  for  the  bedside 
>1  ndyof  this  highest  comportment  of  medical  knowl- 
edge in  which  science  and  art  lie  down  together. 


CHAPTER   II. 
THE  CHRONIC    DISORDERS   OP  GASTRIC    DIGESTION. 

The  clinical  therapeutics  of  the  diseases  of  the 
stomach  is  a  subject  of  great  practical  importance. 
The  diseases  of  no  other  organ  come  more  fre- 
quently under  the  care  of  the  physician,  produce 
more  annoyance  or  suffering,  and  yield  more  surely 
to  judicious  treatment. 

This  chapter  on  the  chronic  disorders  of  gastric 
digestion  is  not  intended  to  be  an  exhaustive  one. 
^Etiology,  pathology,  and  symptomatology  will  be 
considered  only  in  so  far  as  they  bear  on  differ- 
ential diagnosis  and  treatment.  The  cure  of  any 
chronic  disease  is  largely  comprised  in  its  aetiology, 
and  a  correct  diagnosis  is  an  essential  preliminary 
to  rational  treatment. 

It  is  not  often  possible  to  make  a  complete  ana- 
tomical diagnosis  of  a  disease  of  the  stomach. 
Moreover,  morbid  anatomy  is  only  a  symptom,  and 
a  lesion  of  the  mucous  membrane  is  not  always 
present.  Neither  is  an  ^etiological  classification 
practical.  The  same  cause  may  originate  a  variety 
of  disorders.  Alcohol  may  produce  hydrochloric 
superacidity  or  subacidity,  or  gastritis.  Tuber- 
culosis may  be  accompanied  in  its  early  stage  by 
chemical  or  motor  insufficiency  of  the  stomach, 
with  cough  and  vomiting  from  the  irritation  of  the 


II        CUKoNli'    l>lsoKl>KKS    <>\-    i.AVI'lill      DIGESTION. 

supersensitive  ends  of  the  vagus  by  the  food.  The 
inadequacy  is  uol  due  to  a  gastric  Lesion,  but  to 
tubercular  toxaemia.  Hydrochloric  superacidity 
sometimes  aids  in  the  preparation  of  the  nutritive 
soil.  Gastritis  with  a  raw  and  fiery  tongue,  an- 
orexia, ami  diarrhoea  is  the  form  which  belongs  to 
advanced  phthisis.  Chronic  digestive  disorder,  with 
and  without  a  Lesion  of  the  mucous  membrane, 
-'•.ins  to  be  the  most  useful  general  classification. 

However  closely  dyspepsia,  in  the  end,  may  be 
associated  with  errors  in  diet,  the  derangement  of 
1 1  it-  process  of  digestion  is  nearly  always  due,  iii  the 
beginning,  to  disturbance  of  cell  secretion  or  to  im- 
paired muscular  movements.  There  is  no  Lesion  of 
the  mucous  membrane.  Ih'iic-  dyspepsia  may  be 
briefly  defined  as  gastric  insufficiency  without  al- 
tera! inn  of  structure. 

The  impaired  movements  and  defective  secretion 
are  the  local  manifestations  of  a  constitutional 
state.  "Who  would  find  the  cause  of  dyspepsia 
must  look  beyond  the  stomach  to  the  thin  and  im- 
pure blood,  to  the  weak  and  tired  nerve  centres,  to 
impaired  cell  activity  throughout  the  body.  Per- 
verted secretion  is  often  the  result  of  defective  cell 
nutrition.  The  fault  may  lie  in  the  lack  of  tissue- 
forming  material  in  the  blood;  or  this  important 
nutritive  fluid  may  be  surcharged  with  the  pro 
ducts  of  defective  metabolism,  or  with  poisonous 
materia]  absorbed  from  the  alimentary  canal  or 
left  in  the  circulation  in  hepatic  or  renal  insuffi- 
ciency. Thus  we  find  it  in  the  anaemias,  chloro- 
sis. p>ut.  chronic  rheumatism,  lithaemia,  malaria. 
syphilis,  and  chronic  nephritis  ;  or  it   may  prove  to 


CHRONIC    DISORDERS    OF   GASTRIC    DIGESTION.        L5 

be  the  legacy  of  former  acute  illness  or  infection 
disease.  Tuberculosis  and  alcoholism  are  also  com 
mon causes.  But  the  chief  factor  in  the  causation  of 
dyspepsia  -always  present,  always  active,  affecting 
either  secretion  or  muscular  movement,  or  both  i 
impaired  nerve  supply.  This  weakness  or  perver- 
sion of  the  regulating  or  controlling  action  of  the 
nervous  system  may  be  of  central  origin  or  re- 
flected from  a  distant  or  functionally  associated  or- 
gan. The  great  clinical  masters  have  often  noted 
the  frequency  with  which  dyspepsia  occurs  in  the 
neurotic; — an  individual  with  congenital  instability 
of  nerve.  The  part  that  heredity  plays  preponde- 
rates ;  but  impaired  innervation  is  not  rarely  the 
result  of  the  reckless  perseverance  and  unrest  of 
modern  life.  Dyspepsia  finds  many  a  victim  on  the 
rugged  highway  along  which  honors  lie  to  be  gath- 
ered and  worn.  Sudden  reverses  of  fortune,  in- 
tense emotion,  moral  shock,  great  sorrows,  the 
prolonged  strain  and  often  intense  agony  of  the 
critical  periods  of  life,  leave  exhausted  nerves  and 
dyspepsia.  These  patients  are  all  primarily,  or  as 
a  result,  neuropathic.  Nothing  further  need  be 
written,  we  hope,  to  impress  the  principle  that,  if 
we  wish  to  cure  dyspepsia,  our  therapeutic  purpose 
must  reach  beyond  the  stomach  to  the  underlying 
defect  of  constitution,  or  vice  of  nutrition,  or  patho- 
logical nerve  state. 

But  this  is  not  all.  Defective  alimentation — over- 
eating, improper  food.  and.  indirectly,  starvation 
through  exhaustion  of  the  nerves  of  organic  life — 
must  be  considered  as  a  possible  cause  by  destroying 
the  equilibrium  that  obtains  in  health  between  the 


l(j       CHRONIC    DISORDERS    OF   OASTRIC    DIGESTION. 

quantity  of  gastric  juice  secreted  and  the  chemical 
work  required  of  it.  Thus  the  stomach  is  unequal 
to  its  task.  An  excessive  use  of  the  carbohydrates 
is  a  well-recognized  cause  of  lithaemiaandof  neuras 
thenia,  and  these  originate  dyspepsia  through  their 
depressing  psychical  states  ami  the  exhaustion  of 
the  nerves  presiding  over  secretion  and  muscular 
action.  There  is,  however,  no  satisfactory  reason 
for  doubting  thai  errors  of  diet  always  give  rise,  al 
all  events  in  the  beginning,  to  the  lesions  of  gasl  ric 
catarrh. 

Chronic  gastritis  is  frequently  the  sequel  of  dys- 
pepsia. It  often  follows  the  acute  disease,  which  is 
only  rare  because  it  is  not  recognized.  Occasional 
transgression  of  dietetic  laws  seldom  results  in  per- 
sisted pathological  changes.  Habitually  recurring 
patchy  congestion,  initiated  by  some  mechanical  or 
chemical  irritant  contained  or  developed  in  the 
food,  may  not  subside  while  the  stomach  is  taking 
it-  rest,  and  the  tissues  and  nutritive  processes  are 
moulded  into  conformity  with  the  morbid  condition. 
Passive  congestion  of  the  stomach  in  disease  of  the 
liver.  Lungs,  heart,  or  spleen,  or  from  venous  ob- 
struction by  the  pressure  of  a  tumor  or  enlarged 
gland,  is  accompanied  by  the  secretion  of  a  large 
quantity  of  mucus  and  a  diminution  of  hydrochlo- 
ric acid,  and  undue  fermentation  with  its  conse- 
quences results.  Aineinia  with  its  weak  heart  act- 
in  a  similar  manner.  Chronic  gastritis  may  he  sec- 
ondary to  renal  disease,  or  form  a  part  of  the  his- 
tory of  arterio  capillary  fibrosis.      Not  a   few  of  the 

most  obstinate  cases  have  for  their  cause  an  endar- 
teritis of  loiii;-   standing,    or  amyloid  defeneration 


CHRONIC    DISORDERS   OF   OASTRIC    \)U  I  KSTlnN.        L7 

from  exhausting  purulent  formation.  Again,  ;< 
naso-pharyngeal  catarrh  or  bronchitis  may  initiate 
and  food  the  fermentative  process  by  the  decom- 
posing mucus  or  pus  finding  its  way  into  I  In-  i<> 
mach.  The  successful  management  of  chronic  gas- 
tritis depends  largely  on  the  detection  and  removal 
of  the  underlying  cause  that  gives  its  type  to  the 
disease. 

Gastric  ulcer  is  a  common  lesion.  It  is  pre-emi- 
nently a  disease  of  women,  and  is  usually  preceded 
and  accompanied  hy  a  disease  of  the  blood,  such  as 
anaemia,  chlorosis,  or  the  thin  blood  after  labor  ; 
by  diminished  alkalinity  of  the  blood,  as  in  oxalu- 
ria  and  uricaemia  ;  and  hy  hydrochloric  superacid- 
ity  of  the  gastric  juice.  Virchow's  theory  that  the 
simple  ulceration  results  from  the  plugging  of  the 
nutrient  artery  of  the  part  and  digestion  of  the  in- 
farct, seems  to  satisfactorily  explain  many  cases. 
The  endarteritis,  thrombosis,  or  embolism  may  be 
the  consequence  of  the  diminished  alkalinity  and 
the  fibraemic  state  of  the  blood.  Syphilis  and  tu- 
berculosis are  well-known  causes  of  the  specific 
ulcers. 

A  predisposition  to  cancer  is  inherited  ;  its  devel- 
opment is  supposed  to  be  excited  by  chronic  irrita- 
tion, and,  probably,  by  a  specific  germ. 

Atrophy  of  the  gastric  glands  is  due  to  paren- 
chymatous or  interstitial  inflammation,  to  acute  or 
chronic  degeneration,  to  infectious  or  wasting  dis- 
ease like  typhoid  fever  or  tuberculosis,  and  to  innu- 
trition from  prolonged  distention  or  extreme  dila- 
tation of  the  stomach.  Chronic  inflammation, 
ulceration,  cancer,  and  atrophy  are  the  lesions  of 


L8       CHRONIC    DISORDERS   OF   GASTRIC    DIGESTION. 

the  mucous  membrane  which  often  accompany  the 
chronic  disorders  of  the  digestive  process.  Bui 
gastric  inadequacy  is  nol  always  manifested  in 
morbid  tissue  changes.  What  are  the  varieties  of 
dyspepsia,  and  in  wiial  way  can  we  deted  the  un- 
healthy variations  from  tin-  physiological  process  i 
The  modern   methods  of  examining  the  gastric 

juice  are  familiar  to  the  profession  and  o 1  not  be 

reviewed  in  tins  short  chapter.    Always  of  value,  the 
analysis  is  in  some  cases  essentia]  to  a  correct  secre 
tory  diagnosis,  and  often  enables  us  to  see  where 
we  could  only  guess  at  the  truth.     It   is  a  useful 
guide  in  the  administration  of  drugs  to  supplemenl 
the  gastric  juice.     But  it  is  too  great  a  burden  to 
the  physician  and  too  disagreeable  to  the  patient 
to  become  popular  with  the  profession.      Stomachal 
chemistry  is  of  very  great  scientific  interest,  is  an 
aid  to   treatment  and    diagnosis,  but    it    is  n<>1    so 
easy,   nor  so  essential,  nor  so  clear  in  its  sugges 
tions  (the  inferences  drawn  from  it  are  remarkably 
contradictory)  as  to  allow  one  to    conscientiously 
urge   its  general  adoption.     A  word   of  warning 
should  also  here  be  given.     Stomachal  chemistry  is 
reducing  treatment  to  a  very  simple  formula — hj 
drochloric  superacidity  demands  alkalies   in  large 
doses,   subacidity    indicates    the    administration   of 
hydrochloric  acid.     We  shall  see,  a  little  further  on, 
how  narrow  and  irrational  is  this  method  of  treat 
nient.     Again,    it  is  assumed  that  a   certain  secre 
tory  defect  is  so  indelibly  stamped  on  the  mucous 
membrane  that  it  continuously  goes  wrong   in    tin- 
way  and  in   no  other.     This  is  a  general  truth  ap- 
plicable  to  the  grand  types.    But  no  other  organ  is 


CHRONIC    DISORDERS  OF   GASTRIC    DIGESTION.        19 

so   fantastic  and   variable  in  its  work  as  fche  sto- 
mach- a  thought,  a  feeling,  an  emotion  may  infln 
ence  it ;  and  to  a  degree  its  secretion  changes  with 

every    varying  stimulus    or  nerve   sl.it <■    or  blood 
supply. 

The  most  important  constituent  of  the  gastric 
juice,  from  a  pathological  point  of  view,  is  fche 
hydrochloric  acid.  It  is  not  the  state  (combined  or 
free)  of  the  hydrochloric  acid,  but  the  quantity  se- 
creted by  the  mucous  membrane,  that  is  the  guide. 
A  large  quantity  of  albumin  requires  only  a  very 
small  amount  of  pepsin  for  its  hydration  in  a  proper 
medium  ;  and  it  has  not  been  demonstrated  that  too 
little  pepsinogen  is  ever  secreted  in  any  other  condi- 
tion than  glandular  atrophy.  Theoretically  this  is 
true,  but  practically  the  administration  of  pepsin  is 
of  great  utility  when  it  is  necessary  to  prescribe  a 
largely  nitrogenous  diet  in  glandular  atrophy,  com- 
bined with  hydrochloric  acid,  and  without  hydro- 
chloric acid  in  defective  absorption.  The  presence 
of  a  large  quantity  of  peptones  arrests  peptoniza- 
tion, but  the  process  of  hydration  recommences  on 
the  addition  of  a  new  supply  of  pepsin.  The  ab- 
normal quantity  of  hydrochloric  acid  secreted  is  the 
index  of  the  disturbance  of  the  second  and  prepara- 
tory stage  of  the  successive  development  of  the  di- 
gestive process,  which  reaches  its  climax  of  chemi- 
cal changes  in  the  intestine.  But  from  a  clinical 
point  of  view  gastric  motility  is  even  more  impor- 
tant than  gastric  secretion.  When  the  movements 
of  the  stomach  are  perfect  and  the  pylorus  does  its 
work  efficiently,  there  are  no  gastric  symptoms  un- 
less the  mucous  membrane  be  supersensitive.     The 


•.'(•       CHRONIC    DISORDERS   OF   CiASTRIC    DIGESTION. 

stomach  does  a  grand  chemical  and  preparatory 
work  of  its  own  in  peptonization,  uncovering 
starch,  liberating  fat,  and  unbinding  muscular  tis 
sue;  bul  it  is  its  duty  also  to  proted  the  duodenum 
and  fco  dispense  to  it  slowly  and  within  the  righl 
time  the  properly  prepared  and  well-mixed  chyme. 
h  is  "ii  the  unhealthy  variations  of  hydrochloric 
arid  and  the  abnormal  muscular  movements  of  the 
stomach  thai  we  have  found  it  of  mosl  value  at  the 
bedside  to  base  the  classification  of  dyspepsia,  and 
it  is  accordingly  as  these  two  factors  arc  increased, 
diminished,  or  irregular  that  a  deviation  from  the 
state  of  health  can  he  said  to  exist. 

(iastric  dyspepsia  with  increased  formation  of 
hydrochloric  acid  is  usually  associated  with  one  of 
the  neuroses,  and  occurs  in  two  varieties — super 
acidity  and  supersecretion.  In  simple  superacidity 
the  fasting  stomach  is  found  empty  ;  in  continuous 
supersecretion  the  stomach  in  the  early  morning, 
before  eating  or  drinking,  contains  one  or  more 
ounces  of  gastric  juice,  which  may  or  may  not  be 
superacid.  Both  predispose  to  gastric  ulcer  (mark- 
edly so  in  anaemic  women),  and  are  frequently  ac- 
companied  by  dilatation  from  pyloric  spasm  and 
organic  fermentation,  and  sometimes  also  by  down 
ward  displacement  of  the  stomach  and  of  the  first 
part  of  the  duodenum.  The  hydrochloric  acid  may 
he  secreted  in  such  quantity  and  so  rapidly  as  to  at 
once  stop  the  action  of  the  saliva,  which  should 
continue  in  the  stomach  from  tvn  minutes  (Ewald) 
to  half  an  hour  (Van  den  Velden).  Organic  fer- 
mentation docs  not  occur  unless  -as  may  happen 
when  dilatation  and  more  or  less  atrophy  are  pre- 


CHRONIC    IHSORDIOKS   OK   OASTRIC    DIGESTION.       21 

sent — the  hydroehlorie  acidity  falls  below  ".7  per 
cent.  Tliis  is  theoretically  line,  as  may  be  demon- 
strated in  a  test  tube  ;  hut,  clinically,  in  the  sto- 
mach we  not  infrequently  find  organic  fermenl 
and  fermentation  when  the  gastric  juice  is  super 
acid  from  excess  of  hydrochloric  acid.  In  simple 
superacidity  the  appetite  is  increased;  eructations 
are  extremely  acid,  but  usually  without  much  gas  ; 
epigastric  pain  is  paroxysmal  and  severe,  comes  on 
soon  after  meals,  and  is  often  relieved  by  the  inges- 
tion of  water  and  nitrogenous  food.  Proteids  and 
albuminoids  are  rapidly  digested  when  the  food 
mass  is  small  and  permeable,  the  fats  are  partly 
decomposed  by  the  free  hydrochloric  acid  and  the 
fatty  acids  give  rise  to  heartburn,  and  intestinal  di- 
gestion is  delayed  or  arrested  by  the  superacidity 
of  the  chyme.  Diarrhoea  is  often  present.  The 
stomach  wall  is  tonically  contracted  with  painful 
peristaltic  waves.  The  urine  is  quite  alkaline  dur- 
ing digestion,  but  regains  its  normal  acidity,  or  may 
become  excessively  acid,  in  the  interval.  In  super- 
secretion  the  appetite  is  variable  ;  eructations  are 
very  acid,  often  fetid  and  gaseous  ;  pain  is  more  or 
less  continuous,  becoming  paroxysmal  (immediately 
or)  about  three  hours  after  meals  and  about  3 
o'clock  in  the  morning,  and  is  almost  completely 
relieved  by  vomiting.  Gastric  digestion  is  slow  and 
imperfect,  and  gastric  absorption  is  very  much  di- 
minished. The  vomit  is  sour,  often  foul  and  of 
acetic  odor,  and  contains  organic  ferments  and  un- 
digested food  eaten  a  day  or  two  before.  The  signs 
of  dilatation  are  present,  the  greater  curvature  is 
on  a  level  with  or  below  the  umbilicus,  and  morn- 


'.'•J      CHRONIC    DISORDERS   OF  GASTRIC    DIGESTION. 

ing  splashing  and  sometimes  seething  are  easily  eli- 
cited. The  stomach  may  be  distended  and  the 
pylorus  displaced  downward,  and  small  quantities 
of  bile  frequently  regurgitate,  or  in  other  cases 
(which  are  somewhal  rare)  almost  continuously 
flow,  into  the  stomach.  Constipation  is  the  rule, 
but  morning  diarrhoea  is  not  rare.  The  urine  is 
almost  continuously  alkaline  ami  precipitates  the 
phosphates. 

These  varieties  seem  to  be  stages  (the  duration 
of  which  is  very  variable)  in  the  orderly  develop- 
ment of  one  disease.  What  is  the  probable  ex- 
planation? The  digestive  disturbance  seems  to  be- 
gin with  supersensitiveness  of  the  nerves  of  the 
mucous  membrane  and  consequent  excessive  toni- 
city and  excessive  (and  sometimes  continuous)  se- 
cretion through  over-excitation  of  the  motor,  vaso- 
dilator, and  secretory  nerves.  Dilatation  here  does 
not  result  from  atonicity  of  the  muscular  coat.  Its 
pathogenesis  is  the  same  as  the  dilatation  above  an 
intestinal  stricture,  the  same  as  1  he  dilatation  of  the 
left  ventricle  in  aortic  stenosis,  the  same  (and  the 
analogy  is  very  close)  as  the  dilatation  of  the  l.l.nl 
del'  t'i(  mi  excessive  i  nit  a  I  tility  of  its  neck  or  of  the 
deep  urethra.  The  pylorus,  the  powerful  auto- 
matic protector  of  the  duodenum,  contracts  and 
obstructs;  the  gastric  "walls  become  irritable  and 
hypertrophy  ;  fermentation  and  distention  and  loss 
of  compensation  and  dilatation  supervene.  Dimin- 
ished absorption,  mucous  catarrh,  destruction  or 
atrophy  of  the  gastric  glands,  and  diminished  secre- 
t  ion  complete  the  picture.  Ulceral  ion  may  occurat 
any  stage.     On  this  interpretation  will  he  based  the 


CHRONIC    DISORDERS   OF   GASTRIC    DIGESTION.       '.':! 

curative  treatment,  so  far  as  it  depends  on  the  ad- 
ministration of  drugs. 

Dyspepsia  with  diminished  formation  of  hydro- 
chloric acid  is  met  with  most  frequently  in  individ 
uals  with  "weak  stomachs."  Digestion  is  slow  and 
the  lactic-acid  stage  is  prolonged.  The  excess  of 
lactic  acid  is  formed  from  the  sugars  (and  in  sni.ill 
quantity  from  the  starches)  through  the  agency  of 
numerous  fermentation  organisms;  it  may  be  split 
up  into  water,  butyric  and  carbonic  acids,  and  hy- 
drogen. The  hydrochloric  acidity,  even  at  the 
li eight  of  digestion,  does  not  often  rise  above  0.7 
per  cent.  A  little  too  much  work  or  mental  worry 
and  a  little  too  much  food  suffice  to  derange  the 
digestive  process.  The  flatulence  and  acidity  are 
most  marked  two  or  three  hours  after  meals. 

Irregularity  in  the  secretion  and  muscular  move- 
ments of  the  stomach  is  due  to  sympathetic  disturb- 
ance. The  stomach,  through  its  complex  nerve 
connections,  is  in  intimate  relation  with  nearly 
every  organ  in  the  body.  Habitual  speedy  vomit- 
ing without  preceding  nausea  is  nearly  always  re- 
flected. The  gastric  disturbance  comes  on  suddenly 
and  without  warning,  and  varies  in  kind  from  day  to 
day.  In  individuals  with  impressible  nerve  centres 
and  weak  inhibition  the  stomach  is  the  organ  toward 
which  every  little  local  storm  seems  to  wend  its 
way. 

Exaggerated  muscular  movement  of  the  stomach 
is  a  rare  derangement  of  the  process  by  which  food 
is  made  ready  for  assimilation.  The  pathological 
unrest  falls  primarily  on  the  muscular  layer.  The 
exaggerated  peristalsis  commonly  extends  to  the 


■J  I       CHRONIC    DISORDERS   OF   GASTRIC    DIGESTION. 

inteBtine,  the  two  being  intimately  associated  in 
their  movements  a  principle  utilized  to  excite  a  free 
discharge  of  bile  and  to  cause  a  dilated  stomach  to 
empty  itself  by  means  of  the  cold-water  enema,  and 

imt  only  the  solution  bul  the  absorption  oi  aliment 
is  prevented.  It  is  often  associated  with  hyperses- 
thesia  of  the  mucosa  and  a  ravenous  appetite  and 
obstinate  insomnia. 

Gastric  atony   incidental  to  a  state  <>f  weakness 
and  relaxation  of  the  whole  muscular  system  is  a 
common  gastric  defect.     Brain  workers  who  lead 
sedentary  lives  furnish  the  Largest  number  of  its 
victims.     The  muscular  layer  lacks  tone  and  peri- 
staltic movement  is  weak.     The  face  wears  an   ex- 
pression of  fatigue  ;  the  heart  is  weak  and  irritable, 
and  arterial   tension  is  low  :  the   muscles  of  the 
throat  are  flaccid — there  is  a  general  want  of  tone. 
The  gastric  juice  is  normal  ;  digestion  is  slow,  but 
complete  if  not   interfered  with  by  fermentation. 
The  appetite  is  unimpaired  and  the  bowels  are  con 
stipated.     A  sensation  of  uneasiness  rather  than  of 
distinct  pain  ;  a  feeling  of  weight  or  heaviness  from 
long-continued  pressure  of  the  food   on  the  same 
spot;  flatulence  from  muscular  weakness  and  vaso- 
motor relaxation  (as  in  the  intestinal  paresis  of  peri- 
tonitis), or  from  regurgitation  of  gas  through  the 
open   pylorus— complete  the  clinical  picture.     The 
extreme  nerve-tire  explains  the  want  of  muscular 
tonicity,  and  the  weak  stomach,  on  account  of  the 
prolongation  of  its  labor,  gets  little  rest.     Unless 
the  process  he  controlled  hy  judicious  treatment  and 
the  organ  and  system  strengthened,  extreme  dila 
tation   will   surely    supervene.      These  patients   are 


CHRONIC    DISORDERS   OF   GASTRIC    DIGESTION.        i~> 

only  cured  by  the  combined  treatment  of  digestion, 
nutrition,  andthe nervous  system.  II  isa  profound 
error  to  throw  them  into  the  greal  drag-net — neu- 
rasthenia. 

There  is  another  form  of  gastric  atony  that  fre- 
quently comes  under  the  care  of  1  he  physician,  and 
which  dates  its  beginning  in  early  life.  One  cannot 
closely  study  these  cases  without  detecting  hcred- 
ity's  powerful  hand  in  their  development — a  variety 
of  the  "  weak  stomach  "  in  which  the  inherited  or 
early  acquired  or  early  manifested  defect  falls  on 
the  muscular  rather  than  the  secretory  system. 
The  muscular  layer  is  undeveloped,  atrophic  as  well 
as  atonic,  and  peristaltically  weak.  Atrophy  of  the 
gastric  and  intestinal  glands  may  rapidly  follow 
dilatation,  and  death  from  malnutrition  close  the 
scene  before  the  morning  of  life  has  passed  ;  or  the 
curse  may  be  suspended  while  the  years  roll  by,  un- 
til finally  the  sword  falls  and  "  slits  the  thin-spun 
life/''  The  stomach  may  be  strengthened  by  care- 
ful feeding,  but  the  vice  of  constitution  is  irremedi- 
able. 

Dilatation  in  either  form  of  gastric  atony  is  com- 
monly associated  with  a  like  condition  of  the  large 
(and  small)  intestine.  Malnutrition  of  the  local 
ganglia  in  all  probability  has  something  to  do  with 
the  glandular  atrophy.  In  no  other  condition  do 
the  symptoms  of  auto-infection  become  so  promi- 
nent. The  epithelium  throughout  the  alimentary 
canal  is  lowly  organized,  and  here  and  there  the 
wall  is  as  thin  as  parchment  and  free  from  glands. 
These  pouches  (favorite  sites  of  which  are  the  cae- 
cum and  hepatic  and  splenic  flexures  of  the  colon) 


20       CHRONIC    DISORDERS   OF   GASTRIC    DIGESTION. 

are  filled  with  decomposing  and  fermenting  faeces. 
The  peptones  fail  to  be  reconverted  into  serum  al- 
bumin, and  the  emulsified  and  split-up  fats  cannot 
be  built  up  into  glycerin  neutral  fats  on  their  way 
through  the  mucous  membrane  to  the  centra]  lac- 
teal or  blood  vessel.  Absorption  is  imperfect,  un- 
selective;  assimilation  is  disordered  and  nutrition 
fails.  Emaciation  is  marked,  and  the  products  of 
fermentation  and  decomposition  and  Incomplete  di 
gesl  ion  absorbed  from  the  alimentary  canal  congest 
the  liver,  irritate  the  nerve  centres,  and  inflame  the 
kidneys.  Hysteria,  insomnia,  or  a  demon-like  mel- 
ancholy which  no  effort  can  throw  <>\'i'  fastens  itself 
on  the  victim.  The  clinical  history,  self-infection, 
the  absence  of  hypertrophied  walls  and  visible  move- 
ments, easily  exclude  dilatation  from  pyloric  ob- 
struction, functional  and  organic. 

Three  methods  have  been  suggested,  apart  from 
the  clinical  history,  subjective  symptoms,  and  phy- 
sical signs,  to  aid  in  the  diagnosis  of  motor  insulii 
cieney.  A  pint  of  olive  oil  (Klemperer)  is  intro- 
duced, and  what  remains  of  it  in  the  stomach  after 
two  hours  withdrawn.  The  difference  represents 
the  quantity  that  has  gone  into  the  duodenum. 
The  objections  to  this  method,  and  the  liability  to 
errors,  are  too  great  to  allow  serious  consideration. 
Of  more  utility  is  the  salol  test,  if  the  kidneys  are 
sound  and  the  read  ion  in  the  duodenum  is  alkaline. 
In  health  salicyluric  acid  appears  in  the  urine  in 
balf  an  hour  (Ewald  and  Sievers),  and  disappears 
in  twenty-four  hours  in  health,  thirty-six  hours  in 
atony,  and  forty-eight  hours  in  dilatation  iSilher- 
steint.     The  third  and   a    verj    'j;>»"\  method   is  to 


CHRONIC    DISORDERS   OP  GASTRIC    DIGESTION.       27 

administer  Leube's  test  meal  or  Ewald's  test  break- 
fast, and  examine  the  contents  of  the  stoni;i.ch  at 
varying  periods  thereafter. 

The  differential  diagnosis  of  dyspepsia  and  chronic 
gastritis  requires  close  study  and  careful  reasoning. 
The  two  diseases  merge  into  one  another,  and  in 
vague  cases  without  clear-cut  features  it  is  difficult 
to  learn  at  the  bedside  with  which  form  we  have  to 
deal.  The  history  of  the  case,  the  order  of  appear- 
ance, and  duration  of  the  symptoms  must  be  taken 
into  consideration  in  the  formation  of  a  conclusion. 
The  known  nature  Of  the  disease  to  which  the  gas- 
tric disorder  is  secondary  may  help  to  clear  up  the 
obscurity.  A  careful  chemical  or  microscopical 
examination  of  the  blood,  of  the  gastric  juice,  and 
of  the  excretions  will  always  prove  of  value. 

The  local  signs  of  chronic  gastritis  are  persistent, 
while  those  of  dyspepsia  are  intermittent  and  ca- 
pricious. The  pain  of  chronic  gastritis  is  more 
severe  when  the  stomach  is  full  ;  in  dyspepsia  it 
may  occur  only  when  the  stomach  is  empty,  and  be 
relieved  by  taking  food.  Violent  paroxysms  of  pain 
in  chronic  gastritis  are  made  worse  by  pressure  ;  in 
dyspepsia  firm  pressure  may  give  relief,  and  an 
interval  of  comfort  follows  each  attack.  Repeated 
vomiting  of  mucus,  or  of  mucus  mixed  with  undi- 
gested food,  is  pathognomonic  of  catarrhal  gastritis. 
Increased  hydrochloric-acid  formation  is  present 
only  in  dyspepsia  ;  in  chronic  gastritis  the  quantity 
of  hydrochloric  acid  is  diminished.  This  is  true  as 
a  general  rule.  In  the  beginning  of  gastritis  the 
irritable  mucous  membrane  not  rarely  supersecretes 
a  superacid  fluid  ;  this  is  particularly  true   if  the 


2S       CHRONII      DISORDERS    OP    GASTRII      DIGESTION. 

gastritis  be  the  sequel  of  a  secretory  neurosis. 
Thirst,  uausea,  and  anorexia  are  more  frequently 
linked  to  an  alteration  of  structure.  In  certain 
mild  forms  of  gastric  catarrh  a  morbid  sensation, 
closely  allied  to  the  sense  of  hunger  and  radiating 
backward  between  the  scapulae,  recurs  at  regular 
intervals;  its  disappearance  on  the  taking  of  the 
first  mouthful  of  food  is  followed  by  nausea;  the 
slighl  irritation  of  the  food  seems  sufficient  to  pro- 
duce dilatation  and  stasis  of  the  Mood  current  in 
the  previously  hyperaemic  mucosa.  In  simple  ca- 
tarrhal gastritis  there  is  excessive  secretion  of 
mucus.  The  symptoms  vary  very  much  with  the 
extent  and  destructiveness  of  the  inflammatory 
process,  with  the  degree  of  glandular  atrophy  and 
dilatation.  The  dilatation  is  mechanically  produced 
by  the  accumulating  mass  of  fermenting  food,  or 
by  infiltration  of  the  muscular  layer  by  inflamma- 
tory products  ;  when  well  marked  its  diagnosis  pre- 
sents no  difficulty.  It  is  not  on  any  one  sign,  bul 
on  the  symptom  group  and  the  results  of  the  ex- 
amination of  the  contents  of  the  stomach,  that  the 
diagnosis  must  he  based. 

The  diagnosis  of  gastric  atrophy  can  he  based 
with  certainty  only  on  the  long-continued  absence 
of  hydrochloric  acid,  pepsin,  and  the  lab-ferment, 
as  proved  by  repeated  examination  of  the  gastric 
juice.  If  there  be  no  stasis  of  the  food  mass  in  the 
stomach,  the  duodenum  may  completely  supplement 
the  gastric  insufficiency  and  no  symptoms  of  dys- 
pepsia make  t  heir  appearance. 

The  symptoms  of  ulceration  are  those  of  super- 
acid dyspepsia — local  pain,  hsematemesis,  and  local 


CHKONIC    DISORDERS   OP   GASTRIC    DIGESTION.       29 

tenderness.     The  tender  spot,   is   usually   circum 
scribed  and  Located  a  few  inches  below  (and  to  the 
left  of)  the  tip  of  the  ensiform  cartilage;  ils  dia 
gnostic  features  are  its  strict  Localization  and   it- 
persistency.     The  pain  of  the  accompanying  super 
acidity  is  relieved  temporarily  by  food   and  drink  ; 
the  pain  of  the  ulceration  is  increased  or  excited  bj 
eating.     Haemorrhage,  if  it  occurs,  is  usually  pro- 
fuse :  care  must  be  taken  to  exclude  acute  inflam- 
mation,  portal  obstruction,   cancel-,   and  toxaemia. 
Enlargement  of  the  spleen  is  also  accompanied  by 
gastric  haemorrhage.    In  hepatic  cirrhosis  the  blood 
may  come  from  rupture  of  a  dilated  oesophageal 
vein. 

Ulceration  may  occur  at  any  age,  is  of  indefinite 
duration,  irregular  in  its  progress,  and  is  often 
relieved  and  cured  by  treatment.  Even  with  the 
aid  of  a  complete  clinical  history,  of  the  subjective 
symptoms  and  the  physical  signs,  we  may  be  un- 
able to  state  whether  ulceration  is  or  is  not  pre- 
sent. Perforation  may  be  the  first  and  only  sign. 
Sudden  and  large  intestinal  haemorrhage  (large, 
tarry  movements),  preceded  by  paroxysmal  gas- 
tralgia,  extreme  pain  in  the  right  hypochondrium. 
and  more  or  less  duodenal  dyspepsia  of  long  stand- 
ing, are  the  symptoms  of  duodenal  ulcer.  In  gas- 
tric ulcer  the  constitutional  state  is  proportionate 
to  the  digestive  disorder. 

In  cancer  the  patient  is  above  -10  years  of  age  ; 
haemorrhage  is  small  and  slow  ;  there  is  rapid  and 
progressive  decline,  and  cachexia  ;  hydrochloric  acid 
soon  permanently  disappears  from  the  gastric  juice  ; 
a  tumor  may  be  felt ;  treatment  gives  little  relief. 


30      CHRONIC    DISORDERS   OF  GASTRIC    DIGESTION. 

;iinl  tlif  constitutional  state  is  oul  of  all  proportion 
fco  the  disturbance  of  gastric  digestion. 

The  exacl  diagnosis  of  disease  lias  its  peculiar 
charms;  at  all  events,  in  difficult  cases  it  is  the 
floweringof  medical  science.  Bu1  after  the  flow- 
ers  should  come  the  fruit.  Turn  we  now  to  treat 
in. 'lit  -t.>  tin1  consideration  of  the  moral  manage 
in. 'lit.  h\  -'inn',  diet ,  and  medicinal  agencies  which 
clinical  experience  lias  shown  to  be  of  value  in  the 
palliation  or  cure  of  the  chronic  disorders  "I"  gastric 
digest  ion. 

The  moral  management  of  these  diseases  has  not 
received  the  attention  that  it  merits.  We  wish  t<> 
urge  its  importance  in  the  cure  of  those  cases  in 
which  the  weakness  or  derangement  of  the  central 
nervous  system  is  well  marked  when  this  state  is 
a  primary  a  etiological  factor.  In  the  cure  of  neu- 
rasthenic dyspepsia  it  is  the  keystone  to  the  arch; 
it  is  the  one  means  of  rolling  away  the  cloud  that 
darkens  the  pathway  of  the  neurotic.  These  indi- 
viduals have  no  will  power  or  reserve  force,  and  in 
no  other  way  can  we  aid  them  in  throwing  off  the 
delusion  that  they  are  incurable.  It  is  our  duty  to 
make  every  endeavor  to  impress  the  patient  with 
the  fact  that  his  case  is  thoroughly  understood.  A 
correci  anatomical  and  pathological  diagnosis  will 
enable  the  physician  to  state  with  precision  what 
can  be  done.  Firmness  and  kindness  of  heart  are 
the  means  of  winning  confidence.  Faith,  inspired 
by  truth,  honesty,  and  manly  bearing,  stimulates 
and  tones  the  nervous  system  and  unbinds  the  will. 
No  one  doubts  the  power  of  expectant  attention. 
Digestion  is  dominated  by  the  nervous  system,  and 


CHRONIC    DISORDERS   OF   GASTRIC    DIGESTION*.       31 

the  centres  controlling  secretion  and  muscular  move 
ment  are  re-represented  in  the  cortex.     The  physi 
cian  who  fails  in  the  moral  management  loses  an 
essential  aid  in  the  cure  of  these  chronic  cases. 

Not  the  moral  management  alone  is  of  import- 
ance ;  the  life  of  the  patient  must  he  on  a  physio- 
logical basis.  Insist  on  slow  and  regular  eating, 
and  not  too  great  a  variety.  The  stomach  is  only 
confused  and  disordered  by  course  dinners.  A  resl 
of  half  an  hour  before  and  an  hour  after  each  meal 
is  a  duty.  Clothing  should  receive  consideration, 
and  in  our  climate  the  whole  abdomen  should  be 
protected  at  all  times  by  a  knitted  bandage  of  wool, 
wool  and  silk,  or  silk.  The  elasticity  supports  also 
the  dilated  stomach  and  gives  comfort  in  obesity. 
The  method  and  frequency  of  bathing  should  be 
suited  to  the  patient's  general  condition.  Careful 
attention  to  every  detail  is  the  price  of  success. 

Hours  of  work,  recreation,  and  rest  are  to  be  pro- 
portioned to  the  severity  of  the  case.  In  the  mild 
cases  the  patient  should  live  in  the  open  air  during 
the  hours  of  sunshine.  A  daily  drive,  or  a  ramble 
and  view  of  a  favorite  landscape,  may  lift  the  mind 
away  from  self  and  the  worries  of  business  and  life's 
daily  cares.  In  the  severer  cases  confinement  in- 
doors may  be  obligatory,  the  bedroom  must  be 
kept  full  of  fresh  air,  and  the  day  be  spent  in  quiet 
enjoyment  in  a  sunny  room.  In  the  grave  cases, 
when  the  nervous  system  is  a  wreck  and  the  func- 
tion of  every  organ  in  the  body  is  in  abeyance — a 
condition  closely  allied  to  prolonged  shock — isola- 
tion, absolute  rest  in  bed,  massage,  electricity,  oxy- 
gen inhalations,  and  a  tissue-building  diet  will  f re- 


.;.'       CHRONIC    DISORDERS   OP   GASTRIC    DIGESTION. 

quently   enable  the  patient   to  emerge    from    the 
restorative  process  fresh  as  if  from  Medea's  charms. 

But  of  more  importance  than  all  else  in  the  treat  - 
in. 'lit  of  these  diseases  is  the  selection  of  a  proper 
diet.  This  is  "the  greal  and  master  thing"  the 
question  of  feeding.  A.nd  right  here  it  is  essential 
that  we  should  clearly  define  the  principles  which 
may  best  guide  us  in  the  adaptation  of  a  diet  to  in- 
dividual cases  of  disease. 

And  first  we  must  protest  against  the  guidance 
of  a  morbid  appetite  and  of  morbid  desires.  The 
"  natural  instincts "  of  the  patient  must  aot  "have 
tree  play."  though  "  they  have  grown  up  under  the 
regulating  force  of  universally  acting  biological 
laws,  under  the  pressure  of  the  sleepless  vigilance 
of  tlie  law  of  survival  of  the  fittest,  and  the  sure 
incidence  <>f  the  laws  of  heredity*'  (Sir  William 
Roberts).  It  might  be  well  to  suggesl  the  possi- 
bility of  the  development  of  types  from  unhealthy 
variations,  which  might  serve  fittingly  to  illustrate 
the  self -avenging  power  of  Nature's  laws.  Every 
form  of  force  is  modified  by  the  nature  of  the  me- 
dium which  manifests  it.  and  the  •'natural  in- 
stincts" of  the  invalid  are  no  better  guides  to 
alimentation  in  disease  than  are  the  delusions  of 
insanity  guides  to  conduct. 

"Find  out  that  course  of  life  which  is  best," 
writes  Pythagoras,  "  and  habit  will  render  it  most 
delightful."  If  reason,  then,  must  define  the  diet, 
on  what  knowledge  should  its  dictates  be  based  \ 
The  answer  is  a  simple  one —on  "the  rational  stan- 
dard of  diet,  as  revealed  in  the  customs  and  habits 
of  the  people,"  as  Sir  William  Roberts  rightly  ob- 


CHRONIC   DISORDERS   <>K   GASTRIC    DIGESTION.        ■>■> 

serves,  and  as  corrected  by  the  known,  digestibility 

and  nutritive  value  of  the  various  articles  and 
classes  of  food ;  on  the  capability  of  the  digestive 
organs  ;  and  on  the  state  and  needs  of  general  nu- 
trition. 

A  cursory  view  reveals  the  fact  that  the  inhabi- 
tants of  the  temperate  zone  live  on  a  mixed  diet  of 
proteids,  albuminoids,  fats,  and  carbohydrates.  It 
would  be  interesting  to  know  something  of  the 
effect  of  these  classes  of  food  on  destructive  meta- 
bolism and  the  building-up  of  tissue.  The  albu- 
minoids and  proteids  increase  nitrogenous  waste. 
When  administered  along  with  the  fats  or  carbo- 
hydrates in  sufficient  quantity  to  supplement  and 
raise  the  force  evolved  in  the  splitting-up  of  the  al- 
bumin in  the  circulating  fluids  to  the  level  of  the 
requirements  of  the  vital  processes,  or  when  the 
storage  of  fat  in  the  system  can  be  utilized  for  this 
purpose,  none  of  the  cells  of  the  body  are  destroyed. 
When  the  quantity  of  albumin  circulating  with  the 
nutritive  fluids  is  not  all  required  to  meet  the  de- 
mands of  the  vital  processes,  within  certain  limits, 
as  defined  by  the  inherent  activity  of  the  cells  and 
that  delegated  or  withheld  by  the  nervous  system, 
new  cells  are  generated.  Peptones  furnish  energy, 
but  do  not  form  tissue.  Tissue  is  built  up  out  of 
unchanged  or  incompletely  digested  proteids  and  al- 
buminoids. Thus  albumin  is  the  great  sustainer  of 
life,  and,  under  proper  conditions,  the  great  builder 
of  tissue.  It  cannot  be  supplanted,  beyond  a  certain 
point,  by  any  other  food.  It  makes  the  blood  richer 
in  red  corpuscles  and  in  haemoglobin,  as  any  one 
can  easily  demonstrate  by  the  haemocytometer  and 
3 


3-1       CHRONIC    DISORDERS   OF  GASTRIC    DIGESTION. 

haemoglobinometer  in  anaemic  and  chlorotic  dyspep- 
tics on  an  exclusively  animal  diet.     It   is  fche  only 

class  of  food  that  can  alone  support  life,  and  it 
forms  the  physical  basis  of  life  in  its  simplesl  and 
primordial  form. 

The  assimilation  of  fche  Eats  is  aided  by  the  pro- 
teids  and  albuminoids.  Fat  diminishes  nitrogenous 
waste,  and  is  intimately  concerned  in  the  nutrition 
of  the  nervous  system,  and  forms  nearly  all  tin- 
fatty  t issue  of  the  body.  The  carbohydrates  never 
enter  into  the  formation  of  tissue,  hut  aid  the  or- 
ganization  of  albumin  and  fat  by  supplanting  them 
in  destructive  metabolism.  Thus  it  is  evident  that 
the  nut  rition  of  the  body  can  be  most  economically 
maintained  at  a  high  point  by  a  due  admixture  of 
these  three  classes  of  food.  But  in  disease  the  ca- 
pability of  the  digestive  organs,  or.  in  the  special 
diseases  under  consideration,  the  capability  of  tip- 
stomach,  imperatively  demands  a  compromise.  But 
an  early  and  cautious  return  to  a  suitable  mixed 
diet  will  suggest  itself  to  the  common  sense  of  the 
physician  as  the  best  method  of  avoiding  the  evils 
of  exclusiveness.  The  excessive  or  exclusive  use  of 
the  carbohydrates  tends  to  dilatation  and  disease  of 
the  stomach  and  intestines,  and  the  individual  is 
pale,  thin-blooded,  weak,  and  bloated.  A  long  and 
exclusive  use  of  the  proteids  and  albuminoids  ti'\\<\> 
to  certain  circulatory  derangements  and  to  nervous 
irritability  ;  while  the  malassimilation  of  fats  is  the 
most  important  factor  in  the  production  of  the 
emaciation  in  the  pre-bacillaiy  stage  of  tuberculo 
sis.  The  physician,  like  the  general  he  should  he. 
must  avail  himself  of  every  opportunity  to  advance. 


OHEONIC    DISORDERS   OF  GASTRIC    DIGESTION.       36 

or  be  ready  to  retreat  under  cover  on  the  first  note 

of  warning,  until  bis  object  has  been  attained. 

In  the  meantime  the  strength  of  the  enemy  unit 
be  correctly  estimated,  or,  to  drop  the  metaphor, 
the  capability  of  the  stomach  must  not  be  exceeded. 
That  all  of  the  food  taken  undergoes  digestion  and 
absorption  is  made  known  by  the  absence  of  the 
clinical  signs  of  fermentation  or  putrefaction,  but 
chiefly  by  the  chemical  or  microscopical  examina- 
tion of  the  urine,  blood,  faeces,  and  contents  of  the 
stomach  about  four  hours  after  meals.  The  sto- 
mach should  be  free  from  fermentation  organisms, 
and  the  stools  show  no  undigested  food  or  unusual 
fcetor.  The  blood  should  become  constantly  richer 
in  red  corpuscles,  or  in  haemoglobin,  or  in  whatever 
element  it  is  found  defective  in  the  first  examina- 
tion. Eosinophile  cells  diminish  in  number,  poiki- 
locytosis  becomes  less  and  less  marked,  and  the  flat 
red  corpuscles  grow  fuller  and  more  biconcave. 
The  changes  in  the  blood  from  day  to  day  form  a 
very  good  index  of  assimilation.  While  the  pa- 
tient is  on  an  animal  diet,  the  presence  of  indican 
in  the  urine  (if  there  be  no  pus  in  the  body)  points 
to  intestinal  putrefaction,  indol  being  a  product  of 
the  putrefaction  of  albuminoids.  The  information 
obtained  in  this  way  is  at  once  practical,  scientific, 
accurate,  and  sure  ;  in  a  large  clinical  experience  it 
has  proved  to  be  a  satisfactory  guide. 

The  application  of  these  general  considerations  to 
the  treatment  of  the  special  forms  of  the  chronic 
disorders  of  digestion  may  now  briefly  command 
our  attention. 

In  dyspepsia  with  increased  formation  of  hydro- 


CHRONIC    DISORDERS   OF   GASTRIC    DIGESTION. 

chloric  acid  the  patient  musl  be  held  strictly  to  a 
diet  of  lean  meats.  The  keeping,  selection,  and 
cooking  of  meats  cannol  be  discussed  In  the  limits 
tions  of  this  chapter.  All  lean  meats  Bhould  be 
broiled  or  roasted,  never  stewed  or  fried.  Thesta 
pie  food  should  be  the  muscle  pulp  <>r  beef  scraped 
or  chopped  free  of  fibrous  tissue,  steak,  roast,  beef, 
or  mutton  chops  or  roasl  mutton.  For  the  sake 
of  variety  one  can  ring  the  changes  od  the  whin' 
inr.it  of  poultry  plainly  cooked,  fresh  white  fish,  or 
raw  oysters  (care  being  taken  net  fco  swallow  the 
tou^li  [>a it  i  served  oil  half-shell  with  lemon,  or  the 
white  of  egg  cooked  just  enough  to  hold  together. 

The    juice    of   a    few    tender    splits   of    eeleiV     or   of 

watercress  or  of  horseradish,  extracted  with  lemon 

juice,  may  he  used  to  give  flavor.  In  the  way  of 
drinks,  a  small  cup  of  black  coffee  (if  there  is  no 
contra-indication)  after  breakfast  and  dinner,  and 
a  small  cup  of  clear  tea  at  noon,  should  he  rec- 
ommended; hut  no  wines  or  alcoholic  drinks  what- 
soever. As  soon  as  healthy  secretion  is  restored, 
the  crust  of  French  roll,  stale  bread  dry  toasted, 
and  a  few  fcablespoonfuls  of  well-cooked  rice  oi 
cracked  wheat,  or  California  wafers  served  with  a 
little  butter  and  salt, jand,  a  few  weeks  later,  spi 
nach,  fresh  English  peas,  string  beans,  a  floury 
potato,  maybe  added  as  the  patient  is  cautiously 
conducted  on  the  way  to  a  normal  diet.  The  juice 
of  ripe  fruits  may  now  also  he  taken  without  harm. 
In  dyspepsia  with  diminished  formation  of  hy- 
drochloric acid,  and  also  dyspepsia  with  impaired 
muscular  movements,  a  diet  of  animal  food  should 
be  ordered   until  there  is  no  longer  any  evidence 


CHRONIC    DISORDERS   OF   GASTRIC    DIGESTION.       ■>,' 

of  fermentation,  and  the  patient  be  then  slowly 
brought  around  to  a  normal  diet.  The  crust  of 
roll,  or  stale  bread  toasted  so  dry  that  it  will  sn;i|>. 
are  peptogenic,  are  more  easily  digested  than  starch, 
are  not  so  liable  to  ferment,  and  may  be  given  along 
with  lean  meat  in  the  beginning  of  treatment.  A 
few  tablespoonfuls  of  bouillon  before  dinner  will 
also  increase  the  secretion  of  pepsinogen.  Animal 
fat— as  butter,  or  a  slice  of  the  boiled  side  of  bacon, 
•or  cod  oil — should  be  given  as  soon  as  the  stomach 
and  intestines  are  free  of  fermentation,  to  aid  in 
toning  and  building  up  the  central  nervous  system. 
But  if  the  fat  denudes  the  tongue  or  encrusts  it 
with  a  layer  of  dead  epithelium,  or  excites  nausea 
or  eructations,  it  must  be  at  once  withdrawn.  In- 
unctions of  animal  fats  or  pancreatized  cod  oil  as  a 
nutrient  enema  may  then  aid.  A  glass  of  hot  ste- 
rilized milk  will  often  prove  of  value  when  sipped 
very  slowly  in  the  interval  between  meals,  or  at  the 
beginning  of  the  meal  as  a  soup.  The  tea  may  be 
made  more  delicious  by  a  slice  of  lemon  and  a  tea- 
spoonful  or  two  of  old  velvety  rum.  A  little  old 
whiskey  or  brandy  may  be  permitted  if  the  heart  is 
weak.  The  rule  to  return  to  a  mixed  diet  suited  to 
the  state  and  needs  of  general  nutrition,  as  rapidly 
as  the  capability  of  the  stomach  will  permit,  here 
also  obtains.  In  dilatation,  soups  and  milk  do  not 
agree  ;  the  small  bulk  and  high  nutritive  value  and 
digestibility  without  irritation  make  lean  meats  the 
staple  food.     Fats  must  be  watched. 

In  dyspepsia  with  exaggerated  peristalsis  the  diet 
must  be  bland  and  unirritating.  Milk  and  its  pre- 
parations, lean  meats,  and  light  farinaceous  food. 


I  BRONIC    DISORDERS  OF   GASTRIC    DIGESTION. 

without  succulenl  vegetables  and  condiments, 
should  be  ordered  until  the  condition  is  controlled 
by  drugs. 

In  dyspepsia  from  sympathetic  disturbance  the 
diel  should  be  fluid  and  non-irritating  as  pepton- 
ized milk  or  milk  gruel,  koumiss,  matzoon,  butter- 
milk, white  of  f-i;\  the  juice  of  beef  or  ol  her  meats 
— while  the  disease  of  which  the  dyspepsia  is  a  re- 
flex is  discovered  and  palliated  or  cured. 

In  chronic  gastritis  clinical  experience  lias  taught 
us  in  the  beginning  of  the  treatment  to  withhold 
starches,  fats,  ami  sweets  :  and  the  less  the  chances 
given  for  fermentation  and  putrefaction  the  sooner 
we  may  expect  a  cure.  The  treatment  proceeds 
along  the  same  line  as  in  weak  stomachs.  Imt  pro- 
gress is  slower  and  minute  attention  must  be  given 
to  every  detail  of  management  and  every  aid  be 
brought  to  bear.  In  venous  stasis,  the  stomach  be- 
ing kept  clean,  the  diet  should  be  such  as  will  least 
irritate,  and  only  enough  albumin  and  fat  to  main 
tain  the  nutrition  of  the  body  be  given.  If  the 
liver  is  involved,  fat  must  be  supplanted  by  care- 
fully selected  cereals  and  fresh  vegetables.  In 
threatened  cardiac  insufficiency,  after  diminishing 
the  work  of  the  heart  and  prolonging  the  period  in 
which  it  may  take  its  rest,  give,  along  with  the  al- 
buminoids and  proteids,  enough  carbohydrates  to 
enable  some  of  the  albumin  to  be  organized,  and 
thus  guarding  also  against  the  storage  of  fat.  The 
diet  of  dilatation  has  already  been  given,  and  arti- 
ficial digestion  is  the  only  additional  indication  af- 
forded by  gastric  atrophy.  Many  details  have  been 
written  at  the  risk  of  becoming  tiresome,  and  many 


CHRONIC    DISORDERS   OF   GASTRIC    DIGESTION.        30 

more  must  be  left  to  the  good  sense  <>('  fche  phj 
cian. 

The  diet  of  gastric  ulcer  must  be  unirritating  to 
the  lesion  of  the  mucous  membrane  and  adapted  to 
the  hydrochloric  superacidity.  It  is  essential  to 
healing  that  the  ulcerated  surface  should  !><•  given 
rest  and  that  distention  of  the  stomach  be  can  •fully 
avoided.  An  exclusive  milk  diet,  since  its  use  and 
recommendation  by  Cruveilhier,  has  given  some 
very  brilliant  results.  Milk,  sweet  and  fresh  and 
partially  peptonized,  and  rendered  alkaline  by  lime 
water  or  (better)  by  calcined  magnesia  or  the  lac- 
tate of  magnesia,  may  be  a  good  diet  to  begin 
with,  administered  in  small  quantities  every  three 
or  four  hours.  It  is  unirritating  and  gives  the 
stomach  little  chemical  and  motor  work  to  do, 
since  it  is  almost  entirely  digested  in  the  duodenum. 
But  milk  cannot  be  given  in  sufficient  quantity  to 
maintain  nutrition  without  stomachal  distention  ; 
and  when,  on  account  of  the  superacidity,  it  does  not 
agree  (as  is  often  the  case),  it  does  a  good  deal  of 
harm.  It  requires  nutrient  enemata  to  supplement 
it,  is  a  very  treacherous  food,  and  no  one  can  tell 
beforehand  when  its  casein  is  going  to  coagulate  in 
clots,  sour,  and  decompose.  Leube,  in  a  very  large 
experience,  has  obtained  the  best  results  from  his 
sarco-peptones  (prepared  also  by  Eudisch,  New 
York).  This  preparation  is  concentrated,  nutri- 
tious, and  unirritating,  but  very  unpalatable.  Pref- 
erence might  be  given  to  Mosquera's  beef  meal  and 
peptone  jelly,  on  account  of  tkeir  greater  pleasant- 
ness to  taste  and  smell.  Meat  juices,  white  of  egg. 
and  fine  muscle  pulp  of  beef,  with  fresh  pepsin,  are 


tO       CHRONIC    DISORDERS   OP   GASTRIC    DIGESTION. 

\-t\  valuable  arid  counterad  the  superacidity  by 
combining  with  the  free  hydrochloric  acid.  We 
are  Beldom  able  to  accomplish  much  by  rectal  feed- 
ing, bul  must  resorl  to  it  when  the  stomach  is  much 
disturbed  and  during  haematemesis.  Rest  in  bed 
and  the  curative  treatment  <>f  the  superacidity  nun 
two  very  important  indications.  The  strict  din 
must  he  continued  for  some  time  after  the  disap- 
pearance of  all  symptoms. 

The  treatment  of  cancer  is  purely  symptomatic. 
A  rest  ii<ted.  mixed  diel  may  be  comfortably  taken 
care  of  in  the  beginning,  hut  as  irritability,  dilata- 
tion, and  atrophy  develop  the  diet  becomes  more 
and  more  exclusive,  until  finally  sepsis  and  inani- 
tion or  peritonitis  close  the  scene. 

Before  passing  from  the  dietetic  to  the  strictly 
medicinal  treatment  something  must  he  said  on 
gastric  cleanliness.  We  all  know  the  radical  revo- 
lution that  cleanliness,  antisepsis,  and  free  drain 
age  have  created  in  surgery.  The  supreme  indica- 
tion in  the  treatment  of  an  inflamed  surface  is  to 
keep  it  clean  ;  and  this  is  pre-eminently  so  when 
the  inflamed  surface  is  a  highly  organized  secreting 
and  absorbing  structure.  Stomach-washing  is  a 
crude  attempt  to  apply  these  principles  of  surgery 
to  1  lie  treatment  of  the  diseases  of  the  stomach. 
In  dilatation  of  the  stomach,  or  gastritis  with  the 
stomach  irritated  hy  the  products  of  micro-organ- 
isms,  in  superacidity  and  supersecretion,  it  does  not 
require  much  experience  to  teach  one  its  value.  It 
is  best  to  employ  the  method  on  retiring,  or  in  the 
early  morning  one  hour  before  breakfast.  The 
patients  soon  learn  to  do  it  themselves,  or  a  nurse 


CHRONIC    DISORDERS   OP   GASTRIC    DIGESTION.        II 

may  be  employed.  Plain  boiled  water  does  the 
work  well,  to  which,  in  hypersesthesia  of  the  mu- 
cosa, a  little  chloroform  water  may  be  added,  and 
thirty  grains  of  subnitrate  of  bismuth  be  given  at 

the  end  of  the  procedure.  Stomach -washing  is  pal 
liative,  but  not  directly  curative,  and  is  liable  to  b< 
very  much  abused.     If  is  often  a   better  plan  and 

more  physiological  to  stimulate  the  stomach,  when 
possible,  to  empty  itself,  by  hot  water,  massage,  and 
electricity.  Change  of  diet,  by  changing  the  cul- 
ture soil  where  fungi  are  present,  also  makes  for 
cleanliness  and  is  very  refreshing.  Drinking  of 
hot  water,  by  washing  and  draining  downward,  is 
also  an  important  aid.  It  also  soothes  the  terminal 
nerves  and  promotes  secretion,  just  as  the  daily 
bath  leaves  the  skin  in  a  healthier  state.  Moreover, 
it  is  a  gentle,  safe,  and  sure  diuretic,  increasing  not 
only  the  urine  water,  but  also  the  solid  excreta  held 
in  solution,  promoting  both  the  waste  and  renova- 
tion of  tissue  by  quickening  the  circulation  of  the 
fluids.  Hot  water  (it  is  needless  to  say  that  it  should 
be  taken  slowly  and  at  the  right  time)  stimulates 
the  heart  and  raises  arterial  tension  without  con- 
tracting the  arterioles,  and,  consequently,  should 
not  be  taken  in  haemorrhage,  monorrhagia,  endar- 
teritis, or  in  valvular  heart  disease  when  compensa- 
tion is  on  the  verge  of  being  disturbed.  Its  di  uretic 
power  makes  it  the  most  valuable  means  we  have 
of  eliminating  from  the  system  the  poisonous  pro- 
ducts formed  by  the  tissues  or  absorbed  from  the 
alimentary  canal. 

The  drugs  most  useful  in  these  diseases  are  such 
as  increase  the  capability  of  the  stomach,  promote 


I.'       CHRONIC    DISORDERS   OP   GASTRIC    DIGESTION. 

healthy  nutrition,  relieve  grave  symptoms,  or  corn- 
liat  the  morbid  process.  A  sweeping  exclusion  may 
be  made  of  all  medicines  that  irritate  the  mucous 
membrane  or  derange  the  chemical  process  <>f  di- 
gesl  ion.  Dosing  with  nauseating  mixtures  can  onrj 
do  harm.  Drugs  should  be  given  with  a  definite 
purpose  in  view,  and  our  aim  in   prescribing  should 

be  to  combine  simplicity,  elegance,  and  power. 

The  capability  of  the  stomach  may  be  increased 
in  many  ways.  In  subacidity  the  mosi  plausible 
thing  to  do  is  to  give  hydrochloric  acid.  It  is  a 
temporizing  expedient,  and,  if  it  does  any  good 
whatever,  certainly  has  no  curative  value.  If  ad- 
ministered it  should  be  given  in  small  doses  re 
peated  three  or  four  times  during  the  active  period 
of  peptonization,  to  avoid  producing  artificial  super- 
acidity.  It  is  more  rational  and  curative  to  excite 
secretion  by  massage,  faradization,  and  drugs.  Tile 
administration  of  alkalies  in  superacidity  suppresses 
a  symptom  temporarily,  hut  afterward  excites 
acid  secretion  ;  to  relieve  the  pain  it  is  necessary  to 
use.  along  with  the  alkali,  an  analgesic.  Calcined 
magnesia  and  the  lactate  of  magnesia  are  preferable 
to  the  alkaline  carbonates,  although  '•soda-mint 
tablets'9  are  popular  and  also  efficient.  Thecura 
live  treatment  strikes  at  the  cause  by  diminishing 
the  irritability' of  the  mucous  membrane  from  which 
the  si i pei--ecretion  results.  The  fluid  extract  of 
coca  (P.,  D.  &  Co.  ».  the  tincture  of  piscidia  erythrina 
in  small  doses,  and  the  English  or  Squibb's  extract 
of  cannabis  indica,  are  the  three  reliable  drugs  for 
this  purpose  Papoid  is  of  value  when  given  before 
the  hot  water  to  aid  in  the  removal  of  mucus. 


CHRONIC    DISORDERS  OP  GASTRIC    DIGESTION.        \'> 

Then  one  or  more  of  the  following  drugs,  on  account 
of  their  physiological  action,  may  be  selected  to 
meet  the  varying  indications  of  defective  secretion 
and  impaired  movements :  The  simple  bitters  in- 
crease the  acidity  of  the  gastric  juice,  and  are  sup- 
posed to  diminish  the  secretion  of  mucus;  thepro- 
per  time  to  administer  them  is  half  an  hour  before 
meals  ;  all  of  them  are  local  irritants,  and  their  use 
should  not  be  continued  longer  than  three  or  four 
weeks.  Ipecac  promotes  the  secretion  of  mucus, 
and  in  small  doses  allays  irritability.  Opium,  mor- 
phine, and  codeine  diminish  acidity,  allay  irritabil- 
ity, and  check  peristalsis  without  affecting  absorp- 
tion. Nux  vomica  increases  the  acidity  of  the 
gastric  juice  and  tones  and  strengthens  the  muscu- 
lar layer.  It  is  the  one  drug  to  use  in  dyspepsia 
with  diminished  muscular  movement.  It  also  in- 
creases the  quantity  of  nerve  force  radiating  through- 
out the  body,  and  this  important  action  may  often 
be  used  to  promote  tissue  building.  If  too  long  con- 
tinued the  discharge  is  excessive  and  waste  of  tis- 
sue results.  Subnitrate  of  bismuth  is  astringent, 
antiseptic,  and  sedative.  Nitrate  of  silver  allays 
irritability  and  is  supposed  to  exert  a  specific  action 
in  catarrhal  inflammation.  Arsenic  inhibits  the  ac- 
tivity of  the  hepatic  cells,  and  is  prescribed  empiri- 
cally in  the  neuroses  ;  in  the  neuroses  of  the  sto- 
mach Fowler's  solution  in  drop  doses,  before  meals, 
is  of  some  value  ;  or  the  bromide  of  arsenic  or  of 
potassium  or  of  sodium  may  meet  an  indication. 
Iron,  the  alkalies,  oxalate  of  cerium,  and  the  stimu- 
lating antispasmodics  are  at  times  of  value  ;  also 
calomel,  cascara  sagrada,   ipecac,   aloes,    rhubarb, 


44-      CHRONIC    DISORDERS   OP  OASTRIC    DIGESTION. 

senna,  and  podophyllin  are  useful  to  gently  touch 

the  liver  or  to  keep  the.  bowels  in  a  proper  state. 
Saliein.  chloroform,  and  camphor  are  antifermenta- 

li\e.  hut  the  best  way  to  prevent  fermentation  is  to 
keep  the  Btomach  clean,  give  the  proper  food,  and 
see  that  enough  hydrochloric  acid  is  present. 

To  discuss  every  indication  in  the  treatment  oi 
these  diseases  of  the  stomach  would  be  to  write  a 
volume  on  therapeutics.  To  summarize,  in  conclu- 
sion : 

1.  Chronic  gastritis  is  rarely,  and  dyspepsia  al- 
most never,  a  primary  local  disease.  Ulceration  is 
a  local  trouble  engrafted  on  a  secretory  neurosis  and 
a  blood  condition.  Atrophy  may  result  from  local 
or  constitutional  disease.  Cancer  may  he  primary, 
or.  rarely,  is  secondary. 

l\  An  accurate  diagnosis  means  more  than  the 
discovery  of  defective  gastric  digestion.  We  must 
know  the  anatomical  state  of  the  mucous  membrane 
We  must  also  know  the  nature  of  the  disturbance 
— whether  of  secretion,  movement,  or  both  ;  the 
source  of  the  disturbance— whether  in  had  habits  of 
life,  in  acquired  or  inherited  defect  of  constitution, 
in  vice  of  nutrition,  in  fault  of  elimination,  or  in 
disease  of  a  distant  or  functionally  associated  organ. 
The  solidarity  of  the  organs  of  digestion  is  a  facl 
of  very  great  importance  in  clinical  medicine,  and 
dominates  the  method  of  managing  their  disorders 
and  diseases.  Their  intimate  relation  through  a 
common  nerve  supply  ;  the  mingling  in  the  portal 
vein,  on  its  way  to  the  liver,  of  the  various  materials 
absorbed  from  the  alimentary  canal  ;  the  division 
and  community  of  theii  labors:  the  integration  of 


CHRONIC    DISORDERS   OP   GASTRIC    DIGESTION.        \'i 

their  differentiated  functions,  make  them  one  in  ac 
tion  and  in  purpose. 

.">.  The  treatment  embraces  more  than  the  man 
agement  of  the  local  disturbance.  The  Local  treal 
ment  is  important  ;  the  stomach  must  be  kept 
rlcin  and  sweet,  its  work  diminished,  its  capability 
increased.  But  the  whole  man  commands  pre-emi- 
nent consideration — his  mental,  moral,  and  physi- 
cal condition.  And  this  necessitates  the  study  of 
the  character  of  the  patient,  the  regulation  of  his 
habits  of  life,  the  prescription  of  palliative  and  cu- 
rat ive  remedies,  and  a  well-regulated  diet.  And  a 
well-regulated  diet  does  not  mean  the  arbitrary  and 
indiscriminate  use  of  certain  articles  of  food,  but  a 
diet  sanctioned  by  reason  and  experience,  adapted 
to  the  state  and  needs  of  general  nutrition,  and  to 
the  capability  of  the  stomach  and  to  the  peculiari- 
ties of  the  patient.  But  of  more  importance  than 
all  else  is  the  complete  digestion  of  the  food  taken  ; 
this  the  physician  must  see  to  by  daily  observation, 
little  changes  in  quantity,  quality,  or  frequency, 
and  by  wearisome  and  prolonged  supervision.  The 
mere  suppression  of  symptoms  will  do  the  patient 
no  permanent  good.  It  is  better  to  restore  than  to 
supplement  secretion,  and  to  correct  than  to  neu- 
tralize superacidity.  The  curative  treatment  is  di- 
rected against  the  chemical  lesion  of  the  fluids  of 
the  body  and  the  malnutritive  state  of  the  cellular 
protoplasm. 


CHAPTER    III. 

A    CLINICAL   STUDY    <>!•'    [NTESTINAL    LNDIGESTION. 

In  the  clinical  study  of  the  disorders  of  digestion 
the  stomach  cannot  be  considered  the  most  impor 
i.nii  division  of  the  alimentary  canal.  In  the  light 
of  modern  research  this  position  must  be  assigned 
to  the  small  intestine,  and  chiefly  to  its  upper  pari. 
It  is  in  the  duodenum,  and  in  the  duodenum  only, 
that  a  mixed  diel  can  he  perfectly  prepared  for 
absorption.  The  work  begun  in  the  kitchen  and 
continued  in  the  mouth  and  stomach  reaches  the 
climax  of  chemical  changes  at  this  point.  Tin'  pre- 
ceding stages  of  digestion  have  heen  preparatory 
and  progressive. 

Duty  and  responsibility  go  hand-in-hand.  When 
the  duodenum  with  its  two  great  appended  glands 
was  supposed  to  play  a  subordinate  and  supple- 
mentary part,  not  much  attention  was  given  to  the 
intestine  in  the  disorders  of  digestion,  and  the  logi- 
cal sequence  was  failure  in  treatment.  The  sto 
inaeh  has  been  much  abused  by  laymen,  and  a 
physician  of  genius  has  seen  in  it  the  origin  and 
source  of  every  form  of  chronic  disease.  No  other 
organ  has  heen  so  maligned  and  maltreated.  It  is 
now  time  that  the  responsibility  should  rest  where 
it  belongs,  and  much  of  the  blame  must  be  trans 
ferred  to  the  intestine.  Vicarious  suffering  is  not 
a  principle  of  law  or  of  Nature  or  of  disease. 


CLINICAL   STUD'S    OF    INTESTINAL    INDIGESTION.      I! 

The  stomach  is  an  antiseptic  receptacle  which 
doles  out  its  contents  to  the  duodenum  in  a  soft, 
semi-fluid,  mixed,  and  slightly  changed  form.  Its 
secretion,  as  docs  the  saliva,  only  acts  on  one  class 
of  foods  and  in  a  very  incomplete  manner.  No 
very  great  quantity  of  nitrogenized  food  is  con 
verted  by  hydration  into  peptones,  and  the  precipi 
tated  casein,  proteoses,  liberated  granulose,  and  fat 
are  discharged  into  the  duodenum.  But  be  it  un- 
derstood that  it  is  not  our  purpose  to  underestimate 
the  utility  of  the  work  done  by  the  stomach.  There 
is  much  reason  for  believing  that  it  would  be  disas- 
trous to  have  all  of  the  proteids  and  albuminoids 
converted  into  trypsin  peptone,  which  is  essentially 
a  decomposition  or  erosion  product,  and  one  form 
of  which  is  utilizable  only  in  the  production  of  en- 
ergy and  animal  heat.  Gastric  peptones  can  be 
readily  converted  by  anhydration  into  serum  albu- 
min and  are  available  for  tissue  building.  Pure 
peptones  suffice  to  keep  up  nutrition  (Maly,  Adam- 
kiewicz).  Moreover,  unchanged  albumin  intro- 
duced into  the  rectum  is  absorbed  and  can  maintain 
nutrition  (Ewald  and  Eichhorst),  and  proteoses  are 
even  more  readily  drawn  into  the  circulation.  In- 
complete peptonization  cannot,  therefore,  ""be  ad- 
mitted as  an  argument  against  the  usefulness  of 
the  work  of  the  stomach  in  digestion.  Careful  ali- 
mentation can  maintain  nutrition  in  the  dog  and  in 
man  without  the  intervention  of  a  stomach.  This 
proves  that  the  work  of  the  stomach  is  not  essen- 
tial and  can  be  delegated,  in  certain  favorable  con- 
ditions, to  the  duodenum.  It  detracts  not  one  iota 
from  its  value,  and  the  richness  of  resource  results 


Is     CLINICAL   STUD"\     OP    INTESTINAL    INDIGESTION. 

from  the  developraenl  in  duplicate  and  the  multi- 
ple relation  of  function  to  structure  in  the  evolution 
of  ill*-  digestive  system.  The  stomach  also  does 
important  police  duty  in  destroying  pathogenic 
bacteria  and  ejecting  indigestible,  irritating,  and 
poisonous  substances.  The  cardia  and  pylorus  open 
and  close  opposedly.  The  eyelid,  by  a  beautiful 
provision  of  Nature,  protects  the  organ  of  sight. 
The  muscular  pylorus  holds  the  door  to  the  intes 
tine.  Bui  the  chemical  work  of  the  stomach  is  not 
all  important,  and  this  pouch  is  simply  an  antisep- 
tic, protecting,  distributing,  and  chiefly  preparatory 
receptacle. 

'The  intestine  is  a  digesting,  absorbing,  and  elimi- 
nating  tube,  Our  study  is  restricted  to  the  disor- 
ders of  digestion,  and  absorption  and  elimination 
can  only  receive  consideration  as  causative  factor-. 
Elimination  may  disorder  the  digestive  process  by 
altering  the  chemical  reaction  of  the  intestinal  con- 
tents or  by  originating  a  diarrhoea.  If  the  intesti- 
nal epithelium  loses  its  selective  power,  auto-infec 
tion,  with  its  pernicious  influence  on  the  system  and 
on  digestion,  may  result.  An  excess  of  the  diffus- 
ible products  of  digestion  interferes  with  the  fur- 
ther action  of  the  ferments,  and  deficient  absorp- 
tion predisposes  to  superdigestion  and  organic  pu- 
trefaction and  fermentation. 

The  part  that  the  secretion  of  Brunner's  glands 
plays  in  the  conversion  of  the  food  into  a  Liquid  and 
diffusible  product  is  not  well  known.  This  juice  liq- 
uefies proteids  and  albuminoids,  acts  vigorously  on 
a  ptyalin  product,  maltose,  and  probably  also  on 
cane  sugar,  and  by  iibs  intense  alkalinity  aids  in  the 


CLINICAL  STUDY   OF    [NTE8TINAL   INDIGESTION.    49 

neutralization  of  the  gastric  juice.  Its  defective 
secretion  may  add  to  the  work  that  must  be  done 
lower  down  in  the  alimentary  canal,  and  we  would 

naturally  ascribe  to  its  absence  a  predisposition  to 
the  simple  duodenal  ulcer. 

Incomplete  also  is  our  knowledge  of  the  <nt<  n< 
juice.  Cane  sugar  is  chiefly  prepared  by  its  inver- 
tin,  and  its  alkaline 'carbonate  is  essential  to  the 
maintenance  of  the  proper  reaction  of  the  contents 
of  the  jejunum  and  ileum.  Without  it  the  pancre- 
atic ferments  would  soon  be  rendered  inactive  by 
organic  fermentation  and  putrefaction,  although 
normally  no  bacterial  decomposition  of  proteids  and 
albuminoids  should  take  place  in  this  part  of  the  ali- 
mentary canal,  and  indoland  phenol  and  scatol  and 
marsh  gas  and  hydrosulphuric  acid  should  never  be 
formed  here  in  health.  The  gastric  hydrochloric 
acid  should  be  neutralized  in  the  duodenum,  and 
consequently  the  intestinal  contents  are  nearly  neu- 
tral in  the  jejunum  but  always  faintly  acid  in  the 
ileum.  It  is  the  organic  acids  that  the  enteric 
juice  is  called  upon  to  neutralize,  and  the  mainte- 
nance of  a  proper  chemical  reaction  has  a  good  deal 
to  do  with  the  prevention  and  limitation  of  bacte- 
rial growth. 

The  diastatic  ferment  of  the  bile  acts  feebly  on 
carbohydrates,  and  the  bile  salts  throw  down  the 
proteoses  in  the  form  of  a  flocculent  precipitate. 
The  digestion  of  a  natural  emulsion  of  fat  (cream ) 
is  perfect  in  the  absence  of  the  pancreatic  juice 
(Dastre),  and  about  ninety  per  cent  of  it  is  absorbed 
(Mering,  Minkowski),  but  not  so  in  the  absence  of 
bile.  Without  bile  neutral  fats  are  not  emulsified, 
4 


.'ill     CLINICAL    STUDY    OF    IXTIX'INAL    I  X  1  >h  :  K3TION. 

and  organic  decomposition  is  less  when  bile  is  pre- 
sent, [ts  antiseptic  properties  are  very  feeble 
i  though  it  seems  doI  fco  be  a  v  ery  good  food  for  bac- 
teria), and  it  exerts  its  favorable  influence  by  pro- 
moting pancreatic  digestion,  absorption,  and  peri- 
stalsis.   The  liver  is  of  greatest   use  in  metabolism. 

The  pancreatic  juice  puis  the  crown  on  the  chem- 
ical process  of  digestion,  and  its  work  gradually 
loses  itself  in  organic  decomposition.  It  prepares 
QO  way,  is  regal  in  its  advancement,  hut  its  rule  is 
limited  by  precedent  and  hedged  about  with  chem- 
ical and  vital  law.  It  is  with  this  code  that  we  are 
chiefly  concerned. 

Perfect  duodenal  digestion  requires  (a)  a  medium 
of  proper  reaction,  (6)  normal  secretion,  (c)  a  pro- 
portionate  quantity  of  digestible  food  in  a  proper 
physical  condition,  and  (cl)  the  normal  movements 
of  the  food  mass. 

It  may  be  supposed  that  the  best  reaction  for  the 
food  mass  to  possess  is  the  one  which  is  most  fa- 
vorable to  the  action  of  the  digestive  ferments — the 
trypsin,  amylopsin,  steapsin,  and  milk-curdling  fer- 
ment. In  perfect  health  this  is  probably  true ;  in 
disordered  assimilation  rapid  digestion  and  rapid 
absorption  may  both  be  undesirable.  But  our  study 
is  limited  to  disordered  digestion,  and  it  is  our  pur- 
pose to  consider  the  changes  in  the  environment 
and  in  the  conditions  which  disturb  and  delay  the 
process.  It  is  well  known  that  the  pancreatic  fer- 
ments are  most  active  in  a  slightly  alkaline  me- 
dium. The  essential  condition  is  complete  neutral- 
ization of  the  hydrochloric  acid.  In  the  presence  of 
bile  a  feeble  acidity  due  to  organic  acids  does  not 


CLINICAL  STUDY  OF   [NTESTINAL   tNDIGBSTION.     5] 

inhibit  but  probably  increases  their  activity  (Lin- 
denberg).  The  chemical  equilibrium  may  be  de- 
stroyed by  a  too  acid  chyme,  by  a  deficiency  of  the 
duodenal  secretions,  by  excessive  organic  fermenl.i- 
tion,  and  by  too  little  enteric  juice.  The  excess  of 
acid  may  be  taken  in  the  food,  or  it  may  be  devel- 
oped by  organic  fermentation  or  fat-splitting  in  the 
stomach,  or  it  may  be  the  result  of  excessive  secre- 
tion of  hydrochloric  acid  when  the  pancreatic  fer- 
ments are  not  only  rendered  inactive  but  are  also 
destroyed. 

Duodenal  dyspepsia  from  defective  secretion  is  a 
frequent  disorder.  There  may  be  too  little  pancre- 
atic juice  or  too  little  bile,  or  there  may  be  too 
much  bile  of  a  bad  quality,  producing  excessive  peri- 
stalsis. Normal  chyme  is  probably  the  best  stimu- 
lant of  duodenal  secretion.  There  is  the  same  or- 
derly sequence  in  secretion  as  in  the  digestive  pro- 
cess. Through  nervous  association  salivary  is  fol- 
lowed by  gastric  secretion,  and  then  the  duodenum 
and  its  appended  glands  are  aroused  to  action.  The 
alkaline  saliva  promotes  the  secretion  of  the  acid 
gastric  juice,  which  in  its  turn  puts  the  duodenum 
to  work. 

Duodenal  acidity  and  faulty  secretion  are  not  the 
only  disturbing  factors,  but  the  chemical  process 
in  the  intestine  may  be  disordered  by  an  improper 
composition,  or  faulty  preparation,  or  excess  of  the 
chyme.  Gluttony  is  a  frequent  cause.  An  excess 
of  proteids  or  of  carbohydrates  or  of  fats  is  no  less 
pernicious  in  its  ultimate  effects.  Either  form  of 
excess  throws  too  much  work  on  the  duodenum, 
which  will    inevitably    become    inadequate.     Not 


52     CLINICAL   STUD'S    OF    [NTBSTINAL   INDIGESTION. 

i  >nly  is  the  influence  direct,  birl  indirect  also  1 1 1  rough 
defective  preparation  by  the  mouth  and'stomach. 
The  result,  however  brought  about,  isa  chyme  ab 
Qormal  in  quanl  it 3  or  quality. 

The  intestinal  wall  contains  two  sets  of  muscular 
fibres  which  are  often  dissociated  in  their  action 
the  one  regulates  the  calibre  of  the  gut,  the  other 
the  movements  of  its  contents.  Peristalsis  and  to- 
nicity often  act  in  unison,  bul  just  as  often  apart 
from  each  other.  Hot  water  increases  peristalsis 
(Kicord),  but  diminishes  tonicity  ;  cold  water  in- 
creases tonicity  and  ma\  or  may  0.0I  influence  peri- 
stalsis. The  dilated  stomach  spasmodically  emp- 
ties itself,  and  the  same  is  also  true  of  the  dilated 
colon.  The  investigations  of  G-lenard  show  very 
plainly  that  hypertonicity and  inadequate  peristal- 
sis coexist  in  enteroptosis.  The  habitually  relaxed 
pylorus  often  allows  the  food  to  be  hurried  into  I  he 
duodenum.  Neurasthenic-soften  have  flat  bellies, 
cord-like  intestines,  and  constipation.  And  it  is 
important  clinically  to  remember  that  these  two 
kinds  of  muscular  action  may  be  variously  com- 
bined and  localized,  and  restricted  to  divers  parts  of 
the  digestive  tube.  Hypertonicity  disorders  dic- 
tion by  diminishing  the  area  of  absorption  and  in- 
terfering with  the  circulation  of  the  blood.  The 
food  mass  is  not  churned  and  brought  into  ever- 
varying  contact  with  the  mucosa.  Insufficient  and 
irregular  and  excessive  peristalsis  delays  and  disor- 
ders and  decreases  digestion  and  absorption.  Ato- 
nicity  permits  stasis.  Perfect  digestion  requires  nor- 
mal chemical  and  muscular  action.  The  physical 
factor  is  no  less  essential  than  the  chemical  one. 


CLINICAL   STUDY   OK    INTESTINAL    INDIGESTION.      53 

The  recent  brilliant  discoveries  in  the  chemical  pro- 
cess have  drawn  our  eyes  away  from  the  muscular 
layer.  Unhealthy  variations  in  intestinal  tonicity 
and  peristalsis  are  probably  more  pernicious  in  their 
influence  than  defective  duodenal  secretion. 

From  these  proximate  causes  turn  we  now  to  the 
consideration  of  the  remote  ones.  Digestion  is  di:- 
ordered  by  every  disease  which  is  not  purely  local 
in  its  nature  and  effects.  And  our  knowledge 
would  naturally  lead  us  to  expect  this,  since  perfect 
digestion  requires,  in  addition  to  a  right  quantity 
of  healthy  food,  normal  nerve  centres,  a  normal 
supply  of  pure  blood,  normal  secretory  and  absorb- 
ing cells,  and  normal  tonicity  and  peristalsis.  These 
conditions  are  incompatible  with  every  disease 
which  is  not  strictly  local  and  which  involves  a 
part  that  is  not  a  component  of  the  digestive  sys- 
tem, be  that  disease  discoverable  with  the  micro- 
scope in  the  destruction,  arrangement,  or  produc- 
tion of  cells,  or  hidden  under  the  word  "func- 
tional "  in  intracellular  change.  The  neuroses,  de- 
nutrition,  alcoholism ;  anaemia,  chlorosis,  malaria, 
and  other  forms  of  toxaemia ;  organic  disease  of  the 
haematopoietic  or  metabolic,  respiratory,  elimina- 
tory,  circulatory,  or  nervous  systems,  or  of  the  di- 
gestive tube  and  its  appended  glands,  may  be  the 
aetiological  factors.  To  enumerate  the  remote 
causes  of  intestinal  dyspepsia  would  be  to  pass  in 
review  the  entire  number  of  chronic  disorders  and 
diseases  capable  of  disturbing  one  or  more  of  the 
conditions  of  perfect  digestion.  If  we  carefully 
consider  the  clinical  history,  the  subjective  symp- 
toms and  their  order  of  development,  the  physical 


:»|     CLINK    \i.  STUD?    OF    i\ti>ti\\i.   [NDIGB8TIOK. 

signs,  .-ukI  the  result  of  the  chemical  and  micro- 
scopical examination  of  1 1 1 « *  blood,  secretions,  and 

excretions,  \w  will  commonly  !"■  able  to  adopt  a. 
rational  supplementary  treatmenl  directed  against 
the  remote  cause. 

'Hi.'  symptoms  of  intestinal  dyspepsia  are  consti- 
tutional and  local  :  the  two  symptom  groups  are 
born  and  develop  and  live  and  decline  and  r.ill  to 
getlier.  Wo  are  well  aware  that  we  are  now  t  read- 
ing on  disputed  territory  ;  the  battle  yet  rages 
fiercely  and  the  existence  of  neurasthenia  and  this 
great  class  of  dyspepsias  is  staked  on  the  issue. 
Specialism  has  joined  the  fray,  and  the  war  is  to 
the  knife.  Are  these  symptoms,  including  those 
that  are  localized  in  the  digestive  tube,  due  to  neu- 
rasthenia, to  a  functional  nervous  state  without 
anatomical  change  (Beard),  or  to  hyponutrition  of 
the  nervous  system  (Arndt),  or  to  a  general  neuro- 
pathy affecting  alike  the  digestive  tube  with  all  or- 
gans (Charcot),  or  to  dilatation  of  the  stomach  with 
auto-intoxication  sequential  to  chronic  gastritis 
(Leube),  or  to  weakness  and  relaxation  of  the  mus- 
cular layer  (Bouchard),  or  to  dilatation  of  the  as- 
cending (Bouveret)  or  descending  (Trastour)  colon, 
or  to  enteroptosis  (Glenard)  ?  These  questions  can 
best  be  answered  at  the  bedside  by  the  general 
practitioner.  His  is  the  eagle  eye  that  sweeps  the 
whole  field  in  a  flash  and  takes  in  every  detail.  The 
vision  of  specialism  is  all  the  more  intense  because 
of  its  exclusiveness,  but  on  broad  questions  is  very 
apt  to  be  wrong  because  perfect  truth  conns  full 
circle.  It  seems  probable  that  the  neurologist  and 
specialist  in  the  disease  of  the  digestive  system, 


CLINICAL   STUD'S    OF    I  XTKXTI  \  A  I,    INDIGESTION.      00 

though  diametrically  opposed,  are  walking  in  the 
same  beaten  pathway,  in  the  same  virions  circle, 
which  was  long  ago  established  when  nutrition, 
circulation,  and  the  nervous  system  were  linked 
together  in  the  one  law  of  being.  It  may  be  the 
nervous  system  that  is  robbed  of  its  food  and  rest, 
and  brought  to  a  premature  fall  by  hard  hunger  and 
an  overreaching  ambition;  it  matters  not  whether 
the  force  be  scattered  in  the  shock  of  the  lightning 
flash  or  slowly  wasted  beneath  some  burning  ray, 
the  result  is  the  same  —  a  nervous  wreck  more  or 
less  complete.  The  beginning  may  have  been  small 
—a  slight  malaise.  The  end  is  complete  prostra- 
tion. And  associated  with  the  gradual  decline  or 
the  rapid  fall  are  divers  disorders  of  the  digestive 
process.  Neurasthenia  is  one  of  the  grand  causes 
of  gastric  and  intestinal  dyspepsia,  and  affects  pri- 
marily and  chiefly  the  neuromuscular  factor,  the 
physical  process.  Associated  with  it  there  may  be 
normal  secretion  (or  even  hyperchlorhydria)  or  defi- 
cient secretion.  There  may  be  hypertonicity  with 
a  small  stomach  and  cord-like  intestine,  or  there 
may  be  flaccid  dilatation.  But  there  are  essentially 
and  primarily  diminished  peristalsis  and  constipa- 
tion, and  sometimes  complete  stasis.  Now,  it  is  the 
digestive  system  that  first  fails,  and  the  primary 
disorder  is  in  the  chemical  process,  as  is  usually  the 
case  also  when  there  is  "  somewhat  wrong  with  the 
blood. "  Neurasthenia  is  an  entity  ;  so  is  intestinal 
indigestion.  The  one  may  cause  the  other.  Each 
may  exist  alone.  Both  may  result  from  a  common 
cause.  Both  are  parts  of  the  same  circle,  which 
often  becomes  a  vicious  one.     What,  then,  are  the 


56     CLINICAL  STUDY   OF  INTESTINAL    INDIGESTION. 

symptoms  of  intestinal  dyspepsia,  and  on  what  can 
its  diagnosis  be  based  with  certainty  1 

Habitual  malaisi  and  gem  ralcU  bility  are  the  two 
earliest  and  most  persistent  symptoms.  A  little 
work  easily  tires ;  sleep  does  not  refresh  ;  the  mind 
is  uncontrollable,  wandering,  flighty.  The  thinker 
cannot   concentrate     his    attention:     thought  lo^es 

both  in  intensity  and  extension.    The  broadview 

and  firm  grasp  require  a  supreme  effort  which 
leaves  relaxation  and  exhaustion.  The  philosopher 
heeomes  gloomy  and  apathetic,  or  pessimistic  and 
crabbed.  The  preacher  grows  ascetic  and  the 
brightness  of  hope  is  replaced  by  the  gloom  of  de- 
spondency. The  poet  loses  some  of  the  sweetness 
and  clearness  and  continuity  of  Ins  song.  Theai- 
fcisi  fails  in  conception  and  trembles  in  execution. 
The  musician  turns  from  his  instrument — cannot 
rest,  cannot  compose.  The  statesman  becomes 
sour  and  oppressive  and  defiant.  The  merchant  is 
swallowed  up  in  competition.  Poet  and  plowman, 
priest  and  philosopher,  one  and  all,  lose  energy,  per- 
tinacity, strength,  and  happiness  because  the  intes- 
tine does  not  do  its  work  well,  and  the  liver  gets 
clogged,  and  the  blood  contaminated,  and  the  nerves 
irritable  and  tired  and  without  reserved  store  of 
force.  Probably  neurasthenic  first,  dyspeptic  after- 
ward—the  vicious  circle  is  established,  and  neither 
rest  nor  diet  alone,  but  both  combined,  will  cure. 
The  malaise  is  worse  a  few  hours  after  meals  ;  the 
general  debility  is  most  felt  after  a  little  forced  work; 
both  are  usually  at  their  height  about  the  middle  of 
the  afternoon.     Habitual  malaise  and  general  debil- 


CLINICAL   STUDY    OF    INTESTINAL    [NDIOESTION.      5"i 

ity  begin  and  rise  and  decline  an< I  fall  with  the  dis- 
order of  digestion. 

Insomnia,  in  many  cases,  is  a  most  obstim.o- 
symptom,  and  most  frequent  in  the  early  morning 

hours.  Alcoholic  drinks  aggravate  it,  and  the  onl\ 
hypnotic  that  will  give  refreshing  sleep  is  a  clean 
digestive  tube. 

Sensory  disturbances  are  frequent.  Neuralgia, 
hyperesthesia,  paresthesia,  anesthesia,  even  lan- 
cinating pains  like  those  of  locomotor  ataxia,  are 
not  rare.  These  symptoms  bear  no  definite  marks, 
and  are  mentioned  only  on  account  of  their  associa- 
tion with,  and  proportionate  relation  to,  the  degree 
of  the  digestive  disorder. 

The  heart  symptoms  are  reflex  or  mechanical  or 
due  to  auto-infection.  Tachycardia,  which  may  be 
paroxysmal,  is  not  rare.  Tire  heart  muscle  is  nearly 
always  weak  and  the  peripheral  circulation  poor. 
"Vertigo  from  cerebral  anemia  or  auto-intoxication 
is  only  too  common.  Palpitation  seems  to  be  about 
as  often  found  as  in  gastric  dyspepsia.  But  the 
chief  cardiac  sign  is  the  condition  or  behavior  of 
the  right  ventricle.  Flatulence,  especially  in  the 
transverse  colon,  interferes  with  the  action  or  filling 
of  this  ventricle,  and  the  heart  is  pushed  up  and 
laboring  or  rapid,  the  respirations  are  quick  and 
shallow,  the  pulse  small  and  compressible,  and  the 
veins  are  full.  The  dyspnea  may  be  increased  by 
the  clogging  of  the  liver,  auto-infection,  and  con- 
traction of  the  pulmonary  arterioles.  The  symp- 
toms may  be  intermittent  or  remittent  or  parox- 
ysmal, accordingly  as  may  be  the  strength  and 
adequacy  of  the  right  ventricular  wall.     The  heart 


58    CLINICAL   STUD?    OF    INTESTINAL    INDIGESTION. 

may  be  Qol  only  inadequate  but  also  irregular. 
The  diagnosis  of  dilatation  of  the  right  ventricle  is 
not  difficult,  and  the  therapeutic  fcesl  of  fche  relation 
of  tlir  cardiac  trouble  to  the  disorder  of  digestion  is 
conclusive.  Treatment  directed  to  the  heart  alone 
fails.  Digitalis  and  drugs  of  a  similar  nature  do 
harm.  Strychnine  and  oitrogrj  cerin  aid,  but  alone 
arc  inefficient  or  useless;  but,  combined  with  real 
and  a  diet  to  control  flatulence  and  to  cure  the  in- 
testinal dyspepsia,  will  sometimes  restore  the  equili- 
brium,  even  when  the  heart  is  near  the  stage  of 
asystole. 

Distress  and  pain  and  tenderness  are  among  the 
local  symptoms,  but  cannot  be  considered  as  path- 
ognomonic. The  central  figure  on  the  canvas  does 
not  make  the  complete  picture,  and  it  gets  a  good 
deal  of  its  meaning  from  its  relations  and  associa- 
tions: two  peasants  standing  with  heads  bowed 
in  devotion  may  not  attract  more  than  a  passing 
recognition,  but  the  dropped  work,  characteristic 
scenery,  and  sound  of  the  distant  church  bells  wake 
into  expression  a  grand  and  touching  historical 
truth.  It  is  not  on  any  one  sign,  but  on  the  symp- 
tom group,  that  our  diagnosis  must  rest.  Very  little 
meaning  can  be  attached  to  the  time  of  appearance 
of  these  symptoms.  Their  location  should  be  con- 
sidered. But  the  most  valuable  sign  is  a  bruised 
and  heavy  feeling  in  the  belly  during  the  restless 
hours  of  the  early  morning. 

Persistent  flatulence  in  the  snu it I  intestine  is  an 
almosl  pathognomonic  sign  of  intestinal  dyspepsia. 
It  is  greatest  when  organic  putrefaction  and  fer- 
mentation are  most  active,  and  this  usually  occurs 


CLINICAL  STUDY  OF   [NTE8TINAL    [NDIGESTION.     59 

two  or  three  hours  after  a  meal.  It  is  by  no  means 
rare  to  have  gas  diffused  from  the  blood  into  the 
intestine,  but  this  occurs  irregularly  and  intermit- 
tently, and  chiefly  when  the  intestine  is  empty,  and 
is  not  related  to  the  quality  of  the  diet.  When 
poured  into  the  duodenum  from  tin;  stoniaHi  tin- 
clinical  history  and  physical  signs  will  suggest  its 
source,  and  the  urine  and  stools  will  contain  no- 
thing indicative  of  intestinal  indigestion  and  decom- 
position. 

Dilatation  and  displacement  of  the  intestine  is  a 
physical  condition  and  sign  of  some  value.  It  may 
be  due  to  either  distention  or  relaxation  ;  uneven 
tonicity,  especially  when  combined  with  localized 
atonicity,  may  produce  stasis  of  the  intestinal  con- 
tents ;  deficient  peristalsis  and  chemical  and  bac- 
terial decomposition  mechanically  distend.  The 
flexures  of  the  colon  finally  are  displaced  and  fall 
from  lax  ligaments  and  a  flaccid  abdominal  wall. 
This  condition  develops  par  excellence  in  the  neuro- 
muscular form  of  dyspepsia. 

Constipation  and  irregular  stools  vary  with  the 
quantity  of  the  bile,  the  chemical  and  physical  quali- 
ties of  the  intestinal  contents,  and  the  disorder  of 
the  muscular  layer.  Organic  acids,  scatol,  carbonic- 
acid,  hydrosulphuric  acid,  and  marsh  gas  excite 
peristalsis  ;  nitrogen,  hydrogen,  indol,  and  phenol 
have  no  influence  (Bokai). 

The  urine  is  more  or  less  characteristic.  Indol  is 
formed  by  the  decomposition  of  tyrosin,  a  product 
of  trypsin  superdigestion,  and  by  the  bacterial  de- 
composition of  nitrogenous  compounds,  and  it  ap- 
pears in  the  urine  as  indican.     This  process  normally 


GO    CLINICAL  STUD?    OF    [NTB8TINAL    [NDIGBSTION. 

aever  occurs  in  the  small  intestine;  and  a  urine 
containing  an  excess  of  urates,  occasionally  a  few 

crystals  of  uric  acid,  of  specific  gravity  about  L.020, 
a  trace  of  bile,  and  indican  in  excess,  is  almost 
pathognomonic  of  intestinal  indigestion,  if  the  large 
bowel  has  been  previously  washed  out.  The  defi- 
ciency of  acid  in  the  urine  gives  some  idea  of  the 
amount  of  BC1  secreted  (Ewald),  provided  the  in- 
creased alkalinity  of  the  urine  is  not  due  to  the  ab- 
sorption of  alkalies  from  the  food  (Roberts'),  or  t<» 
loss  of  HC1  by  vomiting,  or  to  delayed  absorption 
after  secretion,  or  to  the  formation  of  insoluble 
chlorides  (Jones  and  Quincke).  This  is  a  more 
trustworthy  index  if  the  neutral  or  feebly  acid  urine 
precipitates  the  earthy  phosphates  on  boiling.  The 
alkaline  secretions  diminish  the  alkalinity  of  the 
blood  and  increase  the  acidity  of  the  urine  (Hi'ibner, 
Sticker,  Jones,  and  Quincke).  An  excessively  acid 
urine  of  normal  or  high  specific  gravity,  and  which, 
after  standing  forty-eight  hours,  only  deposits,  it 
may  be,  a  few  crystals  of  uric  acid  or  oxalate  of 
lime,  is  produced  in  this  way.  In  hyperchlorhydria 
the  abstraction  of  acid  is  followed  by  the  with 
drawal  of  alkali  in  excess  to  neutralize  it,  and  the 
reaction  of  the  urine  is  unchanged  or  vacillates. 
Excessive  organic  fermentation  and  consequent  ex- 
cessive secretion  of  the  alkaline  intestinal  juice  are 
the  conditions  underlying  the  formation  of  the  clear, 
highly  colored,  excessively  acid  urine  which  very 
much  delays  deposition. 

The   stools  are  often  characteristic  from  the  fer- 
mentation and  putrefaction  to  winch  they  testify. 


CLINICAL   STUDY    oi<'    [NTESTINAL    ENDIQESTION.      01 

or  from  the  excess  of  unutilized  starch  ,-ind  f';it 
which  they  contain. 

The  diet,  test  is  the  sure  proof,  and  is  based  on  the 
intolerance  of  starches,  fats,  sweets,  and  wines. 
Milk  consequently  is  one  of  the  first  of  the  common 
foods  to  disagree.  Starches,  unless  permitted  to  he 
destroyed  hy  stasis'  and  fermentation,  are  voided  in 
excessive  quantity.  Fats  escape  in  like  manner  in 
the  faeces.  Sweets  add  proportionately  to  the  flatu- 
lence. All  wines,  except  the  oldest  and  lightest, 
are  badly  tolerated.  Make  carefully  selected  and 
scientifically  prepared  and  easily  digested  and  nutri- 
tious meats  the  basis  of  the  diet,  give  one  or  more 
of  the  badly  tolerated  class  of  foods  in  an  easily  di- 
gested form  and  not  in  excess,  regulate  peristalsis. 
examine  the  stools,  apply  our  knowledge  of  physio- 
logical chemistry,  and  the  results  will  be  pretty  de- 
finite and  conclusive. 

Such  are  the  particular  symptoms  of  which  the 
symptom  group  is  composed,  and  it  is  on  the  ever- 
varying  combination  that  the  diagnosis  of  intestinal 
indigestion  is  based — a  diagnosis  which  is  always 
difficult  and  requires  the  very  closest  clinical  stud}". 
The  chemical  condition  of  the  stomach,  both  during 
and  in  the  interval  of  digestion,  the  time  and  thor- 
oughness with  which  it  empties  itself,  its  size  and 
the  tonicity  or  flaccidity  of  its  walls,  can  by  a  few 
examinations  and  tests  be  readily  ascertained  with 
a  good  deal  of  certainty.  But  the  disorder  in  the 
intestine  is  enshrouded  in  difficulty  and  well  pro- 
tected against  chemical  exploration.  But  a  meth- 
odical study  of  the  symptoms  and  of  the  physical 
signs,  the   examination   of  the  urine   and   of  the 


62    CLINK    \l.  STUD'S    OF    tNTBSTINAL    [NDIGESTION. 

stools,  and  a  carefu]  use  of  fche  diel  test,  will  make 
it  possible  to  forma  right  and  definite  conclusion. 
To  each  symptom  we  assign  its  possible  causes— 
what  conditions  and  where  Located  would  produce 

it.  In  turn  we  iivat  cadi  prominent  symptom  in 
this  manner.  We  then  apply  the  same  method  1" 
ill.-  symptoms  as  combined  until  we  arrive  at  the 
possible  explanations  of  the  symptom  group.  In 
this  procedure  the  chemical  or  physical  process  of 
digesl  ion  will  be  found  more  or  less  faulty,  and  pos- 
sibly also  fche  special  detect  be  revealed.  The  ex- 
amination of  the  urine  for  decomposition  products, 
after  the  large  bowel  has  been  previously  thoroughly 
washed  out,  will  confirm  or  further  limit  our  con 
elusions  and  supplement  our  knowledge.  The  diet 
test  may  then  be  made,  and  a  positive  result  will 
give  to  our  inferences  a  high  degree  of  moral  cer- 
tainty. Thismethod  will  turn  on  more  light  than 
any  other  with  which  I  am  acquainted,  hut  it  re- 
quires time,  close  ol^ci-vation,  careful  reasoning, 
and  disagreeable  work.  The  solution  of  a  difficult 
problem  and  the  rational  treatment  of  the  patient 
are  the  rewards  of  the  conscientious  endeavor. 

It  remains  to  differentiate  intestinal  from  gastric- 
dyspepsia,  and  then  to  separate  the  disorder  into 
its  three  great  varieties.  But  be  it  understood  thai 
certain  forms  of  gastric  dyspepsia  always  lead  to 
disorder  of  the  duodenal  process,  and,  rice  versa, 
that  intestinal  indigestion  frequently  deranges  the 
functions  of  the  stomach  ;  and  that  the  two  are 
sometimes  inseparably  hound  together  as  the  main' 
testation  of  a  common  cause  or  as  the  expression 
of  one  disease. 


CLINICAL    STUDY    OK    INTKKTINAI,    [NDIGESTION.      63 

Heartburn,    acidity,    pyrosis,    nausea,    vomiting, 
epigastric   pain  and    tenderness,    are  more  or  l<- 
characteristic  of  gastric  dyspepsia.    Flatulence  can 
be  located  in  the  stomach  and  in  the  intestine  by 
the  physical  signs.     The  time  of  appearance  of  the 
distress  or  pain  must  not  be  given  too  much  consid 
eration  and  value  ;  the  pylorus  is  not  an  incorrupt- 
ible guard  ;  gastric  peristalsis  is  not  a  fixed  quan- 
tity.    The  food  does  not,  like  a  sparrow — to  adopt 
a  favorite  simile  of  early  English  song — fly  in  at 
one  window  and,  after  a  brief  sojourn,  disappear 
through  the  other.     The  entrance  is  usually  rapid 
and  surprisingly  abrupt,  at  least  such  is  the  custom 
in  America  ;  the  duration  of  the  rest  is  very  vari- 
able, and  the  time  of  departure  of  each  individual 
traveller  is  conditioned  by  varying  circumstances. 
Nothing  is  more  remarkable. than  the  likes  and  dis- 
likes, the  whims  and  fancies  and   conduct,  of  the 
human   stomach.     If  it  be  remembered  that   the 
stomach  can  be  filled  with  swallowed  air  or  with 
gas  regurgitated  from  the  duodenum  or  diffused 
from  the  blood,  the  time  of  appearance  and  loca- 
tion of  the  flatulence,  pain,  and  discomfort  will  be 
available  in  differential  diagnosis.     Auto-infection 
is  more  common  in  intestinal  indigestion.     It  may 
well  be  doubted  that  even  in  the  flaccid  gastric  dila- 
tation of  Bouchard  the  toxines  are  formed  in  the 
stomach  and  enter  the  system  from  this  point,  as 
the  neuromuscular  form  of  intestinal  indigestion  is 
the  usual  accompaniment  of  this  condition.     Simple 
emaciation  without  cachexia,  or  a  full  and  ruddy 
face  with  vaso-motor  unrest,  is  the  rule  when  the 
disorder  is  limited  to  the  stomach  ;  the  muddv  com- 


r.l     CLINK    \l.    STUDY    OP    INTESTINAL    INDIGESTION. 

plexion  of  severe  cases  of  Intestinal  indigestion  is 
well  known.  The  mine  is  sometimes  characteris 
lie;  tlif  diet  fcesl  is  of  inestimable  value ;  and  the 
physical  signs  of  gastric  dilatation,  and  of  dilatation 
or  contraction  of  the  colon,  may  be  of  very r  great 
weight.  It  is  not  so  easy  a  matter  as  mighi  be  sup 
posed  to  diagnosticate  and  Locate  dilatation.  In 
using  inspection,  palpation,  and  percussion  it  is  es- 
sential to  remember  the  surface  anatomical  mark 
ings.  About  five-sixths  of  the  stomach  lies  to  the 
left  of  the  median  line  in  the  epigastric  and  hypo- 
chondriac regions,  and  is  entered  by  the  oesophagus 
behind  the  sternal  insertion  of  the  cartilage  of  the 
seventh  rib  :  the  pyloric  extremity  (about  one- 
sixth)  is  to  the  right  of  fche  median  line,  and  ter- 
minates in  the  duodenum  on  a  Level  with  the  tip  of 
the  ensif  orm  cartilage,  and  about  two  inches  to  its 
right,  behind  the  end  of  the  eighth  costal  cartilage. 
Whi'ii  gently  distended  the  fundus  rises  to  the  level 
ot'thetifth  rib,  and  the  greater  curvature  sweeps 
forward  and  downward  to  the  right,  passing  just 
above  the  umbilicus.  It  is  easy  to  see  how  the 
overdistended  stomach  produces  dyspnoea  and  pal- 
pitation by  interfering  with  the  action  of  the  right 
heart  and  diaphragm  and  the  expansion  of  the 
lung.  The  cardiac  end  is  fixed,  the  lesser  curva- 
ture is  only  slightly  movable,  and  the  position  of 
1 1n' greater  curvature  is  conditioned  by  the  degree 
of  distention  of  the  stomach  and  the  displacement 
of  the  pylorus,  which  in  disease  can  sometimes  be 
felt  below  the  lower  border  of  the  liver.  Only  a 
small  area  of  the  organ  is  superficial  and  in  contact 
with  the  abdominal  wall  below  and  bevond  the  left 


CLINICAL   STUDY    OF    tNTESTINAL    [NDIGESTION.      65 

lobe  of  the  liver  and  with  the  left  anterior  thoracic 
wall,  the  latter  forming  the  half =moon-shaped  space 
of  Traube.  The  colon  begins  with  the  blind  pouch 
hi'the  right  iliac  fossa,  ascends  in  front  of  tin-  righi. 
kidney  and  forms  the  hepatic  flexure  near  but  to 
the  right  of  the  gall  bladder,  arches  backward 
across  the  abdomen  above  the  navel  in  a  line  join- 
ing the  tips  of  the  eleventh  ribs,  bends  beneath  the 
lower  border  of  the  spleen,  and  descends  to  the 
upper  part  of  the  left  iliac  fossa,  where  it  terminates 
in  the  sigmoid  flexure.  The  large  bowel  is  very 
movable,  the  transverse  arch  is  particularly  free, 
and  the  caecum,  the  hepatic,  splenic,  and  sigmoid 
flexures  are  the  favorite  sites  of  dilatation.  In  the 
diagnosis  of  gastric  dilatation  the  methods  of  Fre- 
nch (distention  by  CO 2  generated  in  the  stomach), 
of  Lente  (palpation  by  the  sound  moved  about  in 
the  stomach),  and  of  others  (pumping  in  air,  to  dis- 
tend the  viscus,  through  the  stomach  tube)  are  not 
available  in  private  practice.  The  clinical  history, 
the  discovery  of  the  peculiarly  shaped  asymmetri- 
cal bulging  on  the  left  side  and  the  perception  of 
peristalsis,  the  examination  of  the  vomit,  succus- 
sion  splashing  and  seething,  the  location  by  pal- 
pation and  percussion  of  the  greater  curvature  on  a 
level  with  or  below  the  navel,  will  commonly  estab- 
lish the  existence  of  extreme  and  moderate  dilata- 
tion without  a  resort  to  heroic  procedures.  If,  after 
emesis  or  stomach- washing,  a  glass,  or  even  a  pint, 
of  water  is  introduced  into  the  stomach,  the  hue  of 
water  dulness  in  the  erect  position,  which  is  sup- 
planted by  resonance  when  the  patient  lies  down, 
will  locate  the  lower  limit  of  the  stomach  (modified 
5 


66     CLINICAL  STUDY    OF  INTESTINAL   INDIGESTION. 

after  Penzoldt).  The  pitch  of  the  percussion  note  is 
higher  in  clonic  dilatation,  is  commonlj  associated 
with  large  and  foul  diarrhoea)  movements  alternat- 

in--  with  constipation  ;  the  dilated  pari  can  be 
flushed  out  with  a  saline  purge  and  enema,  and  in- 
Bated  with  air  through  a  long  rectal  tube  ;  and  if 
the  stomach  is  not  dilated  the  vomit  and  clinical 
symptoms  peculiar  to  gastrectasia  are  absent.  It  is 
on  these  considerations  that  the  differential  dia- 
gnosis is  founded. 

A  classification  for  use  at  the  bedside  should  be 
simple  and  each  division  clearly  characterized  by 
distinct  symptom  groups.  The  disorders  of  diges- 
tion may  or  may  not  have  a  basis  in  pathological 
anatomy,  and  morbid  tissue  change  may  underlie 
or  accompany  the  unhealthy  variations  in  the  phy 
siological  process.  We  will,  therefore,  consider  dis- 
coverable lesions  as  links  in  the  etiological  chain, 
and  classify  intestinal  indigestion  ac.-oidingly  as 
the  chemical  or  motor  process  or  both  are  disordered. 
The  third  is  a  union  of  the  first  two  varieties,  which 
are  joined  by  a  common  bond,  the  one  being  dietet- 
ic or  neurosecretory,  and  the  other  neuromuscular. 
There  are  two  sets  of  nerve  fibres  (or  one  set  having 
a  double  function)  controlling  secretion,  the  one  in- 
fluencing the  functionating  cells  and  the  other  the 
blood  supply.  The  blood  and  the  nerves,  through 
their  intimate  relations  with  nutrition,  commonly 
fall  together,  and  it  is  chiefly  a  matter  of  historical 
or  scientific  curiosity  as  to  which  was  first  in  the 
field  ;  when  the  patient  consults  the  physician  the 
two  forces  are  usually  closely  allied  in  a  self-de- 
stroying war. 


CLINICAL   STUDY   OF    INTESTINAL   INDIGESTION.      <m 

A  great  deal  has  already  been  said  under  aetiology 
and  symptomatology  that  is  useful  in  the  differen 

tiation  of  the  varieties,  and  the  reader  will  be  spared 
a  repetition.  We  would  add  a  few  words  on  the 
' '  diet  test "  before  passing  on  to  the  treatment.  It 
is  much  more  satisfactory  and  more  definite  and 
more  conclusive  to  make  a  test  tube  of  the  alimen- 
tary canal  than  to  try  to  imitate  natural  digestion 
in  the  laboratory.  If  the  cause  of  the  disorder  is 
dietetic  and  the  abuse  or  error  has  not  established 
a  motor  or  secretory  defect,  the  restriction  of  the 
quantity  and  the  regulation  of  the  quality  of  the 
food  which  composes  the  mixed  diet  will  relieve  the 
symptoms  and  make  the  patient  comfortable.  If 
the  chemical  process  is  at  fault  the  starches,  fats, 
sweets,  and  wines  are  badly  tolerated  and  imper- 
fectly digested.  The  presence  of  dilatation,  consti- 
pation, or  diarrhoea  would  incriminate  the  motor 
factor,  and,  after  its  regulation,  the  toleration  of 
the  foods  normally  digested  in  the  intestine  would 
exclude  defective  secretion.  And  we  read  in  the 
urine,  in  the  faeces,  in  the  physical  signs  and  subjec- 
tive symptoms,  the  result  of  the  experiment  which 
Nature,  the  master  physiological  chemist,  has  per- 
formed under  our  direction. 

Digestion  is  accomplished  in  contact  with,  but 
virtually  on  the  outside  of,  the  body,  and,  as  we 
have  seen,  can  be  deranged  in  two  ways — by  un- 
healthy alimentation  and  by  faulty  secretion  and 
motility.  A  proper  diet  alone  will  effect  a  cure  if 
the  disordered  chemical  process  has  not  established 
abnormal  secretion  or  muscular  movement.  But 
cases  so  simple  rarely  come  to  the  physician's  office. 


68     CLINICAL   STUDY   OP    INTESTINAL    INDIGESTION. 

It  matters  little  through  what  channel  the  digestion 
has  been  disturbed,  [f  the  cause  is  presenl  and 
-i  ill  active  it  is  essential  to  direct  our  treatment  also 
againsl  it;  but  the  damage  persists  after  the  re- 
moval of  the  cause.  The  origin  of  the  trouble  may 
be  in  improper  eating,  or  in  iinphysiological  living, 
or  (if  the  gynsecologist  will  have  it  so)  in  a  diseased 
uterus,  tube,  or  ovary;  but  you  may  regulate  the 
diet,  put  the  manner  of  living  on  a  rigid  basis,  and 
restore  the  generative  organs  to  health  or  cut  them 
out,  and  the  intestinal  indigestion  will  still  persist 
as  a  most  damnable  and  rebellious  legacy.  And  so 
it  is  that  wben  tbo  nervous  system  and  nutrition 
are  brought  under  the  evil  influence,  the  only  hope 
of  cure  lies  in  a  comprehensive  treatment  thai 
reaches  out  beyond  the  local  causal  ft  e  and  digestive 
disorders  and  embraces  the  patient,  that  secures 
good  digestion,  healthy  nutrition,  and  physiological 
living  in  a  suitable  environment. 

We  bave  already  seen  bow  large  a  number  of  in- 
testinal dyspeptics,  through  forced  work  or  through 
hyponutrition,  are  or  become  neuropathic.  And  it 
is  the  neuropath  who  requires  faith  and  hope  and 
contentment  to  lead  him  on.  Mind  is  a  very  subtle 
power  which  modifies  in  some  unknown  way  the 
medium  through  which  it  arises  and  the  parts 
to  which  it  expresses  its  commands.  Thought,  feci 
ing.  and  emotion  are  not  simply  the  aurora  of  mys 
terious  cerebration — the  correlatives  of  material  im- 
pressions. Man  is  not  a  mere  automaton,  conscious 
or  unconscious,  as  heredity,  development,  and  ex- 
perience dictate.  But  the  brain,  in  a  sense,  creates 
and  controls   the  life  of  which   it  is  the  engrafted 


QLINTCAL   STUDY    <>h'    [NTESTINAL    INDIGESTION.      69 

flower.  The  influence  of  the  mind  on  function, 
particularly  on  digestion  and  nutrition,  is  very 
groat.  This  is  the  thread  of  gold,  the  bright  line  of 
truth,  which  runs  through  many  a  grand  error  or 

delusion.  Suggestion  (or  expectant  attention),  all 
unconscious  though  it  he,  is  the  wonder-working 
power  in  amulets,  relics,  magnets,  in  "Christian 
science,'' in  the  "faith  cure,"  in  hypnotism.  Dis- 
belief prevents  or  breaks  the  spell.  The  full  confi- 
dence and  hearty  co-operation  of  the  patient  the 
physician  must  jjossess  in  order  to  be  master  of  tlte 
situation  ;  and  a  hopeful,  cheerful,  contented  mind 
is  a  power  which  makes  for  health. 

It  is  the  business  of  the  physician  to  instruct  as 
well  as  to  bless.  To  do  the  best  that  others  have  done 
and  that  he  himself  can  think  of  for  the  relief  or 
cure  of  disease  is  not  the  fulfilment  of  his  high  call- 
ing. The  physician's  office  is  a  university  hall  as 
well.  And  the  remarkable  ignorance  which  pre- 
vails, among  even  the  most  enlightened  people,  of 
the  plainest  and  simplest  rules  of  healthy  living,  re- 
veals only  too  clearly  the  maimer  in  which  these 
public  duties  are  performed.  Dyspeptics  are  as 
ignorant  and  perverse  as  little  children,  and  we 
must  first  tell  them  how  to  keep  well  before  direct- 
ing them  how  to  get  so.  A  very  large  percentage 
of  the  disorders  of  digestion  are  either  caused  or 
nurtured  by  bad  habits,  and  it  is  most  useful  aud 
essential  to  enforce  physiological  living  as  regards 
bathing,  eating,  rest,  exercise,  work,  sleep,  clothing, 
mental  and  moral  control. 

A  good  morale,  physiological  living,  and  a  proper 
diet    comprise  the  treatment   of  the    mild    cases. 


70     CLINICAL   STIDV    OF    INTESTINAL   INDIGESTION. 

Benefit  Avill  also  be  derived  from  mild  local  and 
general  faradism,  massage  and  Swedish  move- 
ments, outdoor  life  in  a  pure  atmosphere,  and  gene- 
ral tonics.  These  patients  with  slight  disorder  of 
the  digestive  process  are  usually  too  much  drugged. 
Thisoverzeal  on  the  part  of  the  physician  is  to  he 
attributed  to  the  impatience  of  the  dyspeptic.  Per 
manent  results  come  slowly.  The  digestive  organs 
have  beeu  habituated  to  the  performance  of  bad 
work,  and  it  requires  time  to  eat  away  the  iron 
chains.  It  takes  anywhere  from  three  months  to 
as  many  years  to  correct  the  unhealthy  variation, 
which  has  an  inherent  power  of  self-perpetuation, 
and  to  make,  through  force  of  habit,  normal  diges- 
tion the  law  of  being.  Physiology  and  pathology 
diverge  on  a  plane  inclined  downward,  and  progress 
becomes  faster  and  easier  every  day  along  the  route 
selected  by  circumstance.  Law  is  supreme  and  ir- 
repressible both  in  disease  and  in  health,  and  we 
direct  and  fix  the  vital  force  in  the  right  channel 
by  the  proper  changes  in  the  physical,  chemical, 
nutritive,  mental,  and  moral  circumstances  by 
which  its  action  is  conditioned.  Not  the  relief 
simply,  but  the  cure,  of  these  chronic  disorders  of  di- 
gestion requires  time. 

But  in  the  severe  cases  the  treatment  must  com- 
prehend other  remedies  and  meet  other  definite  in- 
dications. The  one  general  condition  which  rises 
above  all  others  in  its  evil  influence  is  self-infection. 
Careful  alimentation  and  strong  natural  barriers 
(active  oxidation  and  a  good  liver)  will  arrest  or  de- 
stroy, while  active  elimination  will  remove,  the  im- 
purities and  poisons.     The  most  powerful  eliminat- 


CLINICAL  STUDY    OF    INTESTINAL   INDIGESTION.     71 

ing  agent  at  our  command  is  water  (pure,  either  at 
spring  water  temperature  or  hot)  in  large  quantities. 
Self -poisoning  is  most  frequent  in  indigestion  ac- 
companied by  dilatation  and  deficient  peristalsis — in 
the  motor  variety  of  the  disorder  ;  in  a  mild  form 
it  is  not  rare  in  chronic  chemical  dyspepsia.  It  is 
well  known  how  frequent  an  accompaniment  it  is 
of  acute  dyspeptic  attacks,  both  when  primary  and 
when  engrafted  on  the  chronic  trouble. 

The  special  treatment  of  the  disorders  of  the  mo- 
tor process  includes  many  remedies  of  very  great 
power — electricity,  massage,  stomach  and  colon 
washing,  abdominal  support,  and  drugs  which  give 
tone  and  strength  and  regular  action  to  the  muscu- 
lar layer. 

Faradism  is  the  form  of  electricity  that  is  of 
greatest  utility.  Central  galvanization,  when  both 
secretion  and  motility  are  faulty,  seems  to  pay  for 
the  time  expended  in  its  application.  The  anode  is 
placed  over  the  cilio-spinal  centre  and  the  cathode 
is  pressed  in  over  the  solar  plexus,  and  an  uninter- 
rupted current  of  about  ten  milamperes  passed 
during  a  short  seance.  Mild  general  and  local  fara- 
dization imparts  strength  and  tone  to  muscles  and 
nerves.  Local  faradization  also  excites  and  regu- 
lates secretion.  One  broad  electrode  is  placed  be- 
hind over  the  cardia  or  lumbar  region  and  the  other 
slowly  moved  all  over  the  stomach,  intestine,  and 
liver.  With  the  intragastric  use  of  electricity  I 
have  no  experience. 

Massage,  like  electricity,  strengthens  the  abdo- 
minal muscles,  increases  gastric  and  intestinal  to- 
nicity and  peristalsis,  improves  the  local  blood  and 


;  .'    CLINICAL   STUDY  OF  INTESTINAL    LNDIGESTION. 

Lymph  circulation,  and  promotes  secretion.  The 
time,  duration,  ami  frequency  of  the  sittings  and 
ruhbings  arc  determined  by  their  objects  and  the 

effect   produced,  each    individual  case  and  Condition 

being  a.  law  unto  itself.     Both  remedies  air  contra 
indicated  by  inflammation,  malignant  disease,  ul- 
ceration, and  generally  also  by  the  active  period  of 

digestion. 

stomach-washing  is  a  very  popular  remedial  pro- 
cedure. I  find  myself  using  it  less  and  less  everj 
day.  It  is  the  remedy  par  excellence  when  there  is 
spasmodic  or  organic  stricture  or  obstruction  of  the 
pylorus.  But  in  atonic  dilatation  the  pylorus  is 
yielding  or  already  wide  open.  The  stomach  is  then 
best  cleaned  and  emptied  by  copious  draughts  of 
hot  water,  massage,  and  local  faradization.  This 
method  stimulates  and  aids  and  encourages  the  or- 
gan to  empty  itself  in  the  normal  way.  Stomach 
washing,  on  the  contrary,  leaves  the  viscus  clean 
hut  flaccid. 

The  same  objection  applies,  though  in  a  less  de- 
gree, to  washing  out  the  dilated  colon.  Mechanical 
distention  does  not  improve  tonicity  and  peristalsis. 
The  procedure  is  useful  to  secure  cleanliness  while 
we  stimulate  and  encourage  by  massage,  electricity, 
and  drugs  the  weak  and  lazy  bowel  to  the  perform- 
ance of  its  work. 

Sulphate  of  strychnine,  in  minute  doses,   is  be- 
yond question  the  best  drug  for  this  purpose.    Tim 
tures  and  wines  aud  syrupy  mixtures  are  object  ion 
able.      Coca  and  damiana  may  also  aid.     Aloin, 
ipecac,  senna,  rhubarb,  or  stronger  purgatives  ma\ 
be  required  for  constipation. 


CLINICAL   STUD'S    OF    [NTESTINAL    [NDIGESTION.      73 

The  abdominal  or  pelvic  supporting  band  a  a 
remedy  in  dilatation  and  displacement  we  owe  to 
the  genius  of  Glenard.  II,  should  extend  high 
enough  to  support  the  stomach  when  it  is  also  di 
lated,  and  be  loose  above  and  lightest  along  the 
lower  iliac  segment.  The  relict  is  often  instantane 
ous  and  remarkable.  A  silk-and-  wool  knitted  ab- 
dominal protector  may  be  worn  beneath  it. 

The  special  treatment  of  chemical  dyspepsia  is 
vested  in  remedies  to  regulate  and  supplement  se- 
cretion. We  possess  few  drugs  which  have  a  selec- 
tive action  on  the  pancreas.  Ether  is  probably  one 
of  them,  but  its  value  on  account  of  this  property 
is  more  than  counterbalanced  by  the  harm  it  does 
in  other  ways.  Pilocarpine  in  small  doses  is  a 
remedy  of  some  utility  and  power.  But  to  increase 
pancreatic  secretion  we  are  forced  to  depend  od  con- 
stitutional remedies — massage,  electricity,  and  nerve 
tonics.  It  is  equally  difficult  to  supplement  the 
pancreatic  juice.  Pancreatin  given  by  the  mouth  is 
either  wholly  or  partly  destroyed,  partly  absorbed, 
and  partly  passed  on  into  the  duodenum.  If  ab- 
sorbed it  is  eliminated  by  the  pancreas  and  liver, 
and  in  large  doses  may  produce  temporary  diabetes 
by  increasing  the  formation  of  hepatic  sugar  (De- 
fresne).  Clinical  experience  commends  its  adminis- 
tration under  the  protection  of  bicarbonate  of  so- 
dium against  the  hydrochloric  acid  of  the  gastric 
juice. 

Many  remedies  promote  the  flow  of  bile,  but 
nearly  all  of  them  possess  the  disadvantage  of  in- 
terfering with  gastric  or  duodenal  digestion.  Merck's 
salicin  sweetens   and  tones  the   stomach   and  in- 


74     CLINICAL  BTUDY   OF    [NTB8TINAL   INDIGESTION. 

creases,  bul  aot  to  a  very  great  degree,  the  flow  of 
bile.  It  has  not  the  inhibiting  influence  of  salicy- 
late of  sodium  on  gastric  and  salol  on  duodenal  di- 
gestion. It  may,  however,  be  necessary  to  admin- 
ister a  cholagogue,  regard  lessor  the  temporary  harm 
which  it  does.  The  administration  of  bile  by  the 
mouth  lias  been  highly  praised  by  Dr.  William  H. 
Porter.  Bile  arrests  artificial  peptonization,  hut  in 
the  stomach  exerts  no  disturbing  influence  on  the 
chemical  process,  increases  secretion,  sharpens  the 
appetite,  and  promotes  nutrition  (Dastre,  Oddii. 
Those  are  very  strong  statements,  and  are,  of  course, 
based  on  the  introduction  of  a  small  quantity  of 
bile  into  the  stomach,  from  which  it  is  absorbed  to 
rapidly  pass  to  the  liver,  the  biliary  salts  thus  gain- 
ing access  to  the  entero-hepatic  circulation.  Bile 
is  a  digestive  secretion,  but  an  excretion  as  well. 
Nature  and  clinical  experience  seem  to  agree  that 
it  is  well  to  keep  it  out  of  the  stomach.  A  chola- 
gogue is  more  apt  to  put  some  new,  fresh  bile  into 
the  duodenum,  where  it  seems  to  belong.  My  lim- 
ited experience  with  its  administration  by  the  mouth 
has  been  unsatisfactory. 

To  increase  intestinal  secretion,  ipecac  in  small 
doses  is  a  pretty  reliable  remedy.  Large  doses  of 
an  alkali  may  be  required  to  supplement  the  alka- 
line carbonate  of  the  intestinal  juice. 

To  control  gross  symptoms  we  have  all  of  the 
symptom  drugs  of  the  materia  medica  at  our  com- 
niand.  We  should  be  careful  to  select  such  as  do 
least  harm  to  digestion.  Antiseptics  are  popular, 
but  do  not  seem  to  do  much  good.  Cleanliness  and 
regular  peristaltic  drainage  are  much  better  than 


CLINICAL  STUDY   OF   INTESTINAL    [NDIGESTION.    75 

antisepsis.  Symptom  drugs  are  rarely  required  if 
the  remedies  which  impart  systemic;  and  loc:al  tone 
and  strength,  regulate  or  supplement  secretion,  and 
secure  normal  muscular  movement  are  combined 
with  a  proper  diet. 

There  is  no  other  disorder  of  digestion  in  which 
the  dietetic  indications  are  so  clear  and  so  absolute. 
Intestinal  errors  are  final,  and  occur  right  in  the 
gateway  of  nutrition.  A  certain  degree  of  freedom 
can  be  given  the  gastric  dyspeptic,  for  the  duode- 
num may  correct  the  blunders  or  negligence  of  its 
assistant.  But  the  diet  of  intestinal  indigestion 
must  be  marked  out  in  hard-and-fast  lines.  In 
the  one  a  limited  license  may  be  tolerated ;  in  the 
other  the  tyranny  is  unrelenting.  In  the  one, 
concessions  may  result  in  a  patched-up  peace  ;  in 
the  other,  the  rule  is  of  iron.  Additions  to  the 
diet  may  be  cautiously  and  reluctantly  made  while 
the  patient  is  under  the  eye  of  the  physician,  but  in 
the  beginning  the  control  must  be  absolute  and  the 
firm  grasp  only  slowly  relaxed  as  the  digestive 
ability  of  the  intestine  increases.  I  am  now  speak- 
ing of  the  cases  in  which  there  is  an  established 
defect  of  secretion  or  of  motility,  be  it  functional 
or  organic,  it  matters  not,  so  long  as  the  Capability 
of  the  digestive  system  is  the  dietetic  guide. 

The  best  diet  in  intestinal  indigestion — audi  state 
it  with  all  the  force  of  a  wide  experience — is  a  diet 
of  lean  meats.  The  worst  foods  are  those  that  re- 
quire the  bile  and  intestinal  juice  to  digest  and 
absorb  them.  Intestinal  dyspeptics  digest  incom- 
pletely and  with  the  greatest  difficulty  sweets,  fats, 
starches,  and  wines.     We   know  that  a  good  deal 


I  LINICAL   BTUDY   OF    INTESTINAL    [NOIGESTION. 

of  starch  in  some  way  disappears  in  the  absence  of 
pancreatic  juice,  the  steapsin  only  splits  neutral  fata 
into  tatty  acids  -and  glycerin  -while  cane  Bugar 
is  inverted  almost  exclusively  by  the  intestinal 
juice.  Milk  occupies  an  intermediate  position,  be 
cause  the  intestinal  juice  lias  uothing  to  do  with  its 
digest  ion.  It  is  a  popular  error  to  suppose  thai  this 
mixed  food  is  chiefly  digested  in  the  stomach.  The 
casein  is  divided  by  the  Lab-ferment  of  the  stomach 
into  hemicasein-albumose,  which  is  absorbed  (with 
or  without  further  peptonization),  and  caseogen, 
which  unites  with  the  alkaline  earths  to  form  cheese 
and  passes  with  the  other  ingredients  on  to  the 
duodenum  (Arthus).  In  the  beginning  milk  may 
completely  relieve  the  gastric  symptoms,  hut  the 
objections  to  it  are  fatal.  It  does  not  give  the  duo- 
denum rest;  it  contains  fat,  lactose,  and  casein  ; 
an  excessive  quantity  must  be  given  to  maintain 
nutrition  ;  it  cannot  be  employed  when  gastric  di- 
latation is  present  as  a  complication.  An  exclu- 
sively milk  diet  is  essentially  a  starvation  cure 
(Ewald).  Whatever  be  the  explanation,  the  phy- 
siologist and  chemical  pathologist  may  decide.  I 
base  my  contention  on  clinical  experience,  and  1 
know  that  a  diet  of  lean  meats  is  the  one  most  cer- 
tain to  give  brilliant  results.  The  diet  may  be  ar- 
ranged in  three  classes — the  exclusive,  rigid,  and 
advanced. 

Exclusive  Diet. — The  lean  meat  of  beef  or  mut- 
ton and  the  white  meat  of  chicken.  The  muscle 
pulp,  free  from  fat  and  fibrous  tissue,  of  the  adult 
animal  only  is  permitted.  The  American  chopper 
in  this  country,  and   the  ( lalante -Debove   pnlpifier 


CLINICAL   STUDY   <>i-'    [NTESTINAL    [XDIGESTION.     77 

in  France,  are  the  best  instruments.  Skimmed 
meat  juices.  Whites  of  eggs  cooked  just  enough 
to  hold  together.  And  to  this  list  maybe  added 
Mosquera's  beef  meal.  Lemon  juice  with  or  with 
out  horseradish.  A  cup  of  weak  coffee  or  tea  with 
out  sugar  and  cream,  or  a  glass  of  hot  water.  This 
is  the  diet  of  the  severest  cases,  and  is  soon  supple 
mented  by  the  articles  of  the  second  class. 

Rigid  Diet. — The  articles  of  the  exclusive  diet. 
Broiled  beefsteak  or  roast  beef.  Roast  leg  of  mut- 
ton or  broiled  chop.  White  meat  of  fresh  fish  (sole. 
whiting,  flounder).  Soft  part  of  raw,  roasted,  or 
broiled  oysters.  Cooked  celery,  watercress,  crust 
of  stale  French  roll.  Dry  toast  with  a  little  butter. 
Clear  and  unsweetened  coffee  or  tea.  A  little  di- 
luted brandy  or  whiskey  may  be  tried. 

Advanced  Diet. — To  the  preceding  articles  may 
be  added  broiled  game,  venison  in  season,  sweet- 
bread, eggs  (poached),  rice,  cracked  wheat,  Califor- 
nia wafers,  wheatina — thoroughly  cooked.  Baked 
floury  potato,  French  peas,  string  beans,  tomatoes, 
and  spinach  (if  no  lithaemia).  Purees  of  fresh  vege- 
tables. The  juice  of  a  few  grapes.  Milk  warm 
from  the  cow  or  sterilized  as  soon  as  drawn.  Tea 
or  coffee  without  cream  or  sugar.  Light  claret  or 
old  dry  sherry.  A  little  Worcestershire  sauce.  N<  > 
veal,  lamb,  hog  meats,  goose,  duck,  cod,  herring, 
salmon,  or  other  very  firm  and  fat  fish  ;  no  old  or 
raw  vegetables,  pastry,  very  acid  or  sweet  fruits ; 
no  cheese. 

This  dietary  is  adapted  alike  to  the  chemical  and 
motor  varieties  of  dyspepsia,  the  varying  element 
being  the  quantity  of  fluid  taken  with  the  meals. 


>    CLINICAL   BTUD1    OF    [NTBSTINAL    INDIGESTION. 

The  dry  diet,  firsl  advocated  by  Chomel,  is  to  be 
used  in  dilatation  and  deficient  secretion.  The  five 
or  six  ounces  of  fluid  should  be  slowly  drunk  after 
tlif  meal,  so  that  the  stimulating  action  <>f  the  dry 

food  on  salivary  and  gastric  secretion  may  be  ob 
tained.  Starving  these  patients  for  fluid  will  not 
cure  them;  in  the  interval  (which  should  lie  long) 
between  meals  enough  water  should  be  ordered  to 
keep  the  urine  in  the  proper  condition,  avoiding 
distention  of  the  stomach  and  emptying  it  by  the 
means  already  delineated.  Hot  water  is  rapidly 
absorbed  and  promotes  downward  peristalsis,  in- 
creases primary  oxidation  and  elimination,  and  is 
almost  essential  in  the  exclusive  diet.  In  hyper- 
chlorhydria  water  can  be  taken  freely  as  a  diluenl 
and  to  prevent  pyloric  spasm  against  the  passage  of 
a  hyperacid  chyme. 

Detailed  and  dogged  supervision  is  the  price  of 
success.  To  prescribe  a  diet  and  then  not  to  Bee 
that  it  is  digested  and  assimilated  is  to  court  failure. 
By  the  right  quantity  and  quality  of  food  and  wa- 
ter the  urine  should  be  kept  free  from  deposit,  of 
normal  slight  acidity,  of  specific  gravity  about 
1.014  or  1.018,  and  without  excess  of  coloring  mat 
ter ;  the  stools  healthy,  the  patient  without  local 
distress  related  to  eating  and  without  abnormal 
flatulence,  and  the  blood  gathering  haemoglobin 
and  red  corpuscles.  These  are  the  clinical  guides  in 
the  continued  use  of  the  systematic  treatment. 

Intestinal  indigestion  is  not  curable  by  drugs 
alone.  The  treatment  must  draw  on  a  richer  store 
of  remedial  powers.  The  much-drugged  and  neg- 
lected baby  soon  withers  and  falls  away  ;  the  well- 


clinical  study   OF   [NTB8TINAL   INDIGESTION.     79 

fed  and  carefully  nursed  child  is  of  more  vigorous 
growth.  The  one  is  a  flower  without  roots  and  as 
weak  as  a  life  without  good  hygiene  and  the  righl 
foods.  The  very  drugs,  the  warm  sunshine  which 
should  be  its  strength,  only  hasten  the  approaching 
decay.  Curative  treatment  is  of  a  more  vigorous 
growth,  running  down  into  the  underlying  sysi»- 
mic  causes  and  twining  its  tender  feeders  about 
each  unhealthy  variation,  and  rising  in  its  gathered 
strength,  through  physiological  living,  normal  secre- 
tion and  excretion,  and  careful  alimentation,  to  a 
right  performance  of  all  the  nutritive  processes. 
We  treat  digestion,  nutrition,  and  the  nervous  sys- 
tem, the  physician  and  patient  standing  shoulder  to 
shoulder  in  the  struggle  to  bring  the  organism 
under  the  dominion  of  the  gentle  forces  which 
make  for  health.  The  powers  of  evil  that  one  can- 
not stay  with  iron  chains  the  sweet  influences  of 
hope,  contentment,  and  quietude  will  sometimes 
lightly  bind. 


CHAPTEE    IV. 

THE   I    M'sA'l'h  »N    Wl»  TREATMENT  OP  CHRONIC 
DIARRHCEA. 

Iris  not  always  possible  to  connect  chronic  diar- 
rhoea with  a  distinct  lesion  of  the  intestine,  aor  can 
we  limit  its  origin  to  functional  or  organic  defect  of 
the  digestive  system.  It  is  by  no  means  rare  to  find 
it  one  of  the  symptoms  of  disease  of  a  distant  organ, 
or  disorder  of  nutrition,  or  defect  of  elimination. 
But  chronic  diarrhoea  is  a  symptom  so  frequent  thai 
ii  may  serve  as  a  convenient  point  from  which  to 
begin  investigation,  so  important  as  to  often  com- 
mand our  whole  attention,  and  so  predominant  as 
to  dictate  the  treatment.  WTienever  present  it 
-lands  out  in  bold  relief  in  the  clinical  picture  and 
necessitates  a  search  for  its  hidden  meaning.  The 
term  "  chronic  diarrhoea  "  may  be  made  to  serve  a 
useful  clinical  purpose,  and  no  apology  need  he  of- 
fered for  selecting  it  as  the  subject  of  a  paper  based 
on  invest  igations  at  the  bedside. 

Fluidity  is  the  most  const  ant  characteristic  of  the 
diarrhoea!  stool.  This  physical  qualit  v  results  from 
excessive  secretion  or  transudation,  or  increased 
peristalsis  and  diminished  absorption.  The  stools 
are  also  altered  chemically  and  microscopically,  but 
the  character  of  the  discharges  varies  very  much 
with  the  age,  diet,  the  nature  and  location  of  the 
disturbance.     The  frequency  of  the  evacuations  is 


TREATMENT   OF   CHRONIC    DIARRHOEA.  81 

also  no  criterion,  and  varies  widely  both  in  health 
and  in  disease.  But  habit  and  oilier  influence 
establish  a  certain  routine  which,  though  it  varies 
with  each  individual,  maybe  taken  as  a  standard. 
The  character  and  freijuency  of  the  stools  Avill 
nearly  always  enable  us  to  make  out  the  presence 
of  the  symptom.  Moreover,  diarrhoea,  whether 
conservative  or  not,  is  always  an  exhausting  pro- 
cess, and  when  long  continued  must  inevitably  af- 
fect the  general  health.  Hence  chronic  diarrhoea 
maybe  denned  as  the  frequent  evacuation  of  the 
fluid,  and  usually  abnormal,  contents  of  the  intes- 
tine, with  more  or  less  impairment  of  the  general 
health. 

A  classification  of  chronic  diarrhoea  based  on  the 
changes  in  the  stools  is  not  desirable.  A  careful 
study  of  the  stools  will  not  fail  to  yield  some  useful 
information.  But  in  the  same  case  the  character  of 
the  stools  varies  from  day  to  day,  and  bears  no  defi- 
nite relation  to  the  lesions. 

A  classification  based  on  etiology  would  be  more 
scientific,  and  stands  in  direct  relation  to  the  ad- 
vanced treatment  which  strives  to  go  beneath  the 
surface  and  strikes  at  causation.  A  careful  review 
of  the  possible  causes  will  aid  very  much  in  formu- 
lating a  rational  treatment,  but  our  knowledge  at 
present  is  too  incomplete  to  enable  us  to  make  a 
scientific  etiological  classification. 

A  nomenclature  based  on  pathological  findings 
is  neither  desirable  nor  practical.  Morbid  ana- 
tomy is  only  a  symptom  of  unhealthy  cell  activ- 
ity, and  widely  different  processes  find  expression 
in  the  same  tissue  changes.  But  the  lesions  must 
6 


THE  CAUSATU  >N    A.ND 

be  taken    into   consideration    in    formulating    the 

treat  int'iit. 

In  studying  a  case  of  chronic  diarrhoea  I  con- 
stantly keep  before  me  t  wo  objects  of  commanding 
importance  :  the  detection  of  the  proximate  and  re- 
mote causes,  and  the  discovery  of  the  nature  and 
Location  of  the  intestinal  lesion.  In  this  way  we 
gain  all  the  information  that  is  of  mosl  value  in  the 
management  of  the  case. 

The  proximate  cause  of  every  diarrhoea  is  Located 
in  the  intestinal  wall.  The  intestine  is  a  secretin-, 
absorbing,  and  eliminating  tube,  which  propels  its 
contents  in  a  peculiar  way,  and  in  which  the  most 
important  part  of  digestion  takes  place.  In  diar- 
rhoea too  much  fluid  is  poured  out  from  the  mucous 
membrane,  or  too  little  fluid  is  absorbed,  or  the 
contents  of  the  intestine  are  hurried  along  too 
rapidly.  It  is  common  to  find  two,  or  even  all,  of 
these  factors  active  in  a  particular  case. 

Diarrhoea  from  supersecretiou  is  a  frequent  va- 
riety. It  is  commonly  due  to  local  irritation,  with 
here  and  there  patches  of  catarrhal  inflammation, 
Jt  is  also  found  in  chronic  nerve  or  blood  states,  and 
may  often  he  traced  to  auto-infection  as  the  remote 
cause.  Chronic  dyspeptic  diarrhoea  maybe  taken 
as  the  type  of  this  form.  Much  mucus  and  a  dis- 
proportionate quantity  of  undigested  food,  espe- 
cially starch,  are  found  in  the  stools. 

The  excess  of  fluid  may  be  an  exudate,  as  in  a 
condition  of  the  mucous  membrane  analogous  to  an 
ec/eina  or  herpes.  Or  the  fluid  may  he  transuded 
in  passive  congestion,  such  as  occurs  in  hepatic  cir- 
rhosis, obstructive  disease   of  the  lungs,  or  imcom- 


TREAT.VIKNT    ni<'   cllljo.MC    DIARRHOEA.  83 

pensated  valvular  disease  of  the  heart.  The  pathog- 
uomonic  sign  of  this  variety  is  the  presence  of 
serum  albumin  in  the  stools. 

The  intestinal  mucous  membrane  is  also  an  eli- 
minating organ,  and  diarrhoea  is  qo1  rarely  due  to 
exaggeration  of  this  function.  The  diarrhoea  of 
chronic  Bright's  disease  and  septic*  emia  are  I  y  |  m  is 
of  this  form. 

Diminished  absorption  maybe  the  starting poinil 
of  a  diarrhoea.  But  a  diarrhoea  originating  in  this 
way  will  not  long  remain  simple,  as  the  resulting 
superdigestion,  fermentation,  and  putrefaction  will 
produce  supersecretion,  exudation,  and  excessive 
peristalsis.  Impaired  absorption  always  forms  one 
of  the  links  in  the  etiological  chain,  and  has  as  much 
to  do  with  the  persistence  as  with  the  causation  of 
diarrhoea.  The  stools  contain  completely  digested 
products. 

Diarrhoea  from  excessive  peristalsis  is  neuromus- 
cular in  origin,  and  occurs  in  its  simplest  form  in 
neurotics  with  lively  reflexes  or  with  hypersesthetic 
mucous  membranes.  Exaggerated  peristalsis,  how- 
ever, usually  results  from  a  local  irritant.  A  stool 
occurs  regularly  and  rapidly  after  each  meal,  and 
consists  chiefly  of  unaltered  food. 

From  this  it  will  appear  that  diarrhoea  is  wholly 
or  in  part  a  conservative  process  in  every  variety, 
except  that  which  is  purely  nervous  in  origin,  and 
this  variety,  it  must  be  admitted,  is  but  rarely  met 
with. 

These  divisions  are  based  on  unhealthy  variations 
in  the  physiological  processes — the  surface-play  of 
concealed  forces.     While  it  will  not  clearly  reveal, 


M  THE  CAUSATION    wi- 

the manner  of  appearanoe  of  tho  diarrho>a  will  sug- 
gest the  salient  features  of  the  underlying  disturb 
ance.  Tho  kind  of  fruit  or  flower  will  enable  us  to 
infer  something  of  the  nature  of  the  seed  and  the 
development  of  the  plant.  It  is  always  difficult, 
and  sometimes  impossible,  t<>  discover  the  remote 
cause,  be  it  located  iii  a  disorder  of  nutrition  or  hid- 
den in  the  disease  of  a  distant  organ. 

Disease  <»f  the  kidneys,  heart,  liver,  lungs,  and 
spleen  must  usually  be  well  marked  in  order  to  pro- 
duce  a  diarrhoea.  Anaemia,  gout,  leukaemia,  Hodg- 
kin's    disease,    scurvy,    syphilis,    tnhercnlosis,     and 

septicaemia  must  also  he  passed  in  review  and  ex- 
cluded. 

A  very  large  percentage  of  all  cases  of  chronic 
diarrhu'a  find  their  origin  in  derangement  of  one  of 
the  three  great  processes  of  nutrition  —digestion,  ab- 
sorption, and  metabolism.  The  perfection  of  each 
one  is  essential  to  the  integrity  of  the  whole  ;  tins 
constitutes  the  solidarity  of  the  nutritive  proce- 
From  a  therapeutic  standpoint  it  is  of  great  utility 
to  locate  the  primary  disturbance.  The  presence  in 
the  urine  of  the  incompletely  elaborated  products  of 
tissue  waste,  such  as  uric  acid  and  the  mates  in  ex 
•  ess,  and  of  pathological  urobilin,  would  point  to 
faulty  kataholism  ;  peptones,  albumin,  or  sugar  in 
the  urine  might  implicate  assimilation  ;  while  the 
discovery  in  the  stools  of  the  digestive  products  in  a 
fluid  and  diffusible  form  would  suggest  defective 
absorption.  But  the  nutritive  disorder  more  often 
takes  its  origin  in  the  digestive  tube,  either  in  ga.-t  ric 
d\ spepsia  or  inflammation,  with  alteration  either  in 
the  chemical  process  or  in  the  muscular  movement  -  ; 


TREATMENT   OK   OMKONIC    DIARRHOEA. 

or  in  intestinal  indigestion  from  faulty  chyme,  bile, 

pancreatic  secretion,  or  intestinal  peristalsis.  An 
insufficient  diet,  of  which  simple  emaciation  will  be 
the  evidence  ;  unhealthy  food  and  impure  drinking 
water,  an  improperly  constituted  diet,  will  often  l»<- 
found  the  initiating  causes,  though  secretion  and 
muscular  movement  be  in  every  way  normal. 

An  important  connecting  link  in  'the  causation 
of  chronic  diarrhoea  is  auto-infection,  which  may 
be  from  the  digestive  or  from  the  general  system. 
Absorption  of  the  products  of  superdigestion,  fer- 
mentation, and  putrefaction  is  one  source  ;  defects 
of  assimilation  and  disassimilation,  increased  cell 
activity  and  tissue  waste,  and  incomplete  elimina- 
tion are  others.  The  quantity  of  toxin es  formed  in 
health  may  be  increased,  or  new  ones  may  be  manu- 
factured in  defective  nutrition,  or  bacterial  pro- 
ducts be  absorbed,  and  self -poisoning  will  result  un- 
less elimination  is  very  rapid.  Some  of  the  toxines 
dilate  and  others  contract  the  blood  vessels  ;  some 
alter  the  blood  as  well  as  the  blood  pressure,  thus 
impairing  secretion  or  causing  exudative  or  produc- 
tive inflammation.  Some  paralyze,  others  excite, 
the  nerves  ;  all  exercise  a  pernicious  influence  on 
nutrition.  The  prevention  and  treatment  of  auto- 
infection  is  the  most  important  part  of  the  manage- 
ment of  chronic  diarrhoea. 

It  has  been  ably  maintained  that  we  never  have 
a  diarrhoea  without  the  presence  of  an  enteritis. 
But  it  is  now  a  fact  pretty  well  established  by  care- 
ful autopsies  that  diarrhoea  frequently  is  not  ac- 
companied by  noticeable  lesions  of  the  intestine. 
From  a  practical  point  of  view  the  detection  of  the 


THE  I    LUS  \  rioN    \ND 

cause  is  of  much  greater  utility  than  the  diagnosis 
and  location  of  the  lesion.  The  chief  advantage  of 
a  knowledge  of  the  anatomical  state  of  the  mucous 
membrane  is  the  light  it  throws  on  prognosis.  But 
the  nature  and  Location  of  the  Lesion  afford  certain 
indications  in  treatment. 
I  have  been  in  the  habit  of  grouping  all  my  ca 

into  two  la rge  classes,  according  as  tin-re  is  or  is 
not  a  marked  lesion  of  the  intestine,  and  try  to  de* 
cide  whether  or  not  ulceration  is  present.  This 
classification  is  somewhat  arbitrary,  but  it  is  usu- 
ally possible  to  group  the  cases  on  this  wide  basis. 
Our  standpoint  is  at  the  bedside,  and  this  broad 
classification,  in  which  minute  anatomical  distinc- 
tions are  not  made,  has  a  practical  bearing. 

In  the  functional  disorder  the  symptoms  are  mild 
or  and  may  be  intermittent;  there  are  no  persist- 
ent [joints  of  tenderness  and  no  thickening  of  the 
bowel,  and  the  stools  contain  no  products  of  inflam- 
mation. 

A  large  number  of  chronic  cases  with  intestinal 
lesions  follow  acute  attacks  that  have  their  remote 
cause  in  the  digestive  system,  or  form  part  of  the 
clinical  history  of  the  acute  infectious  diseases. 
The  persistenceof  pain,  tenderness,  and  fever  would 
indicate  the  presence  of  an  important  lesion.  The 
discovery  in  the  stools  of  much  epithelium,  mucus, 
and  unaltered  bile  pigment,  of  pus,  blood,  false 
membrane,  and  pieces  of  tissue  from  the  intestinal 
wall,  would  ]  >rove  the  trouble  to  be  organic.  Chronic 
gastritis  with  chronic  diarrho -a  is  accompanied  by 
chronic  enteritis. 

Ulceration  of  the  intestine  is   simple,  syphilitic, 


TREATMENT  OP  CHRONIC    DIARRHfEA. 

tubercular,  or  malignant.  The  signs  of  a  Lesion,  in 
many  cases  the  strict  localizal  ion  and  persistence  of 
a  painful  and  tender  point,  the  presence  and  con- 
tinuance of  much  pus,  blood,  and  mucus  without 
tenesmus,  and  the  detection  of  bowel  tissue  in  the 
stools,  establish  the  diagnosis  of  ulceration.  Intes- 
tinal carcinoma  is  usually  locate* I  in  the  rectum,  and 
can  commonly  be  felt  by  the  finger  throng]  1  the 
anus  ;  cachexia  and  rapid  decline  will  also  point  to 
malignancy.  Simple  ulceration  results  from  a  se- 
vere catarrh,  or  from  acute  or  chronic  follicular  in- 
flammation, and  commonly  involves  a  large  extent 
of  surface.  Syphilitic  and  tubercular  ulceration  is 
more  strictly  localized,  and  the  disturbance  of  the 
digestive  process  above  the  lesion  is  from  excessive 
peristalsis.  In  syphilis  we  may  get  a  specific  his- 
tory or  characteristic  skin  lesion,  or  a  persistent 
headache  with  periodical  exacerbations  and  at- 
tended by  insomnia  and  unwonted  irritability  of 
temper,  an  early  endarteritis,  or  other  sign  of  this 
protean  malady.  Tubercular  ulceration  is  almost 
never  found  apart  from  pulmonary  tuberculosis, 
and  the  rapid  pulse,  dry  skin,  hectic  fever,  and  lo- 
calized physical  signs  will  confirm  the  suspicion. 
The  absolutely  pathognomonic  sign  is  the  discovery 
of  the  tubercle  bacillus  in  a  shred  of  the  bowel  tis- 
sue found  in  the  stools. 

The  character  of  the  stools,  the  persistent  points 
of  tenderness,  and  other  physical  signs,  taken  along 
with  the  clinical  history,  will  locate  the  lesion  with 
a  good  deal  of  exactness.  The  lower  the  lesion  the 
more  frequent  and  more  painful  are  the  move- 
ments.    It  is  rare  to  find  the  small  bowel  alone  dis- 


88  THE   <  A.USATION    A.ND 

eased.  The  large  bowel  is  nearly  always  involved. 
Commonly  associated  with  it  is  disease  of  the  lower 
ileum.  It  is  near  the  ileo-caecal  valve  thai  bacteria 
aboundj  that  fermentation  and  putrefaction  are 
mosl  active,  that  irritants  long  remain  in  contact 
with  the  mucous  membrane.  When  either  the 
small  intestine  or  the  colon  i>  alone  diseased  there 
will  be  periodical  attacks  of  diarrhoea;  when  both 
are  involved  the  diarrhoea  is  likely  t<>  be  continu- 
ous. Pain  occurring  jusl  before  a  movement  is 
usually  located  in  the  colon.  Tenesmus  is  presenl 
only  in  proctitis,  [ndicanuria,  tally  stools,  recur- 
ring shghl  icterus,  and persistenl  flatulence  in  the 
small  intestine  are  pathognomonic  of  duodena]  de- 
fect. Much  unaltered  bile  pigment  and  mucus  in- 
timately mixed  with  the  fasces  point  to  the  small 
intestine.  When  the  trouble  is  located  in  the  as- 
cending colon  the  stools  are  soft,  muco-feculent, 
and  little  yellow  globules  of  mucus  are  visible,  and 
hard  fecal  lumps  coated  with  mucus  from  the 
lower  half  of  the  large  gut.  When  from  the  rec- 
tum the  stools  consisl  of  yellowish  or  blood-stained 
white-of-egg  mucus  or  mucus  and  fibrin  shreds  ; 
and  the  lower  colon  ami  rectum  may  furnish  ;i 
shred  or  cylinder.  Conned  of  a  network  of  fibrin 
tilled  with  mucus,  with  here  and  there  an  epithelial 
cell  on  the  surface,  or  exfoliated  casts  of  false  mem 
hrane. 

Having  briefly  reviewedsuch  points  in  aetiology, 
differentia]  diagnosis,  and  Localization  as  can  he 
utilized  at  the  hedside.  turn  we  now  to  the  treat- 
ment. 

Good  hygienic  surroundings, a  regulated  lite,  and 


TREATMENT   OP   CHRONIC    DIARRHCEA.  89 

a  proper  .diet  will  often  suffice  to  cure  a  mild  diar 
rfioea.  But  the  severe  cases  must  l>e  subjected  to  a 
rigid  regime.  Many  of  th<'se  patients  have  tried 
everything,  done  nothing  thoroughly,  andlostfaith 
andhope.  An  important  strategic  point  is  already 
gained  if  we  win  the  confidence  and  arouse  so 
strong  a  desire  to  get  well  as  to  cause  every  energy 
to  be  bent  in  the  direction  that  we  dictate.  The 
successful  management  of  these  cases  depends  as 
ninch  on  the  co-operation  of  the  patient  and  the  de- 
tailed observance  of  directions  as  on  the  skill  of  the 
physician.  It  is  not  enough  to  order,  but  instruc- 
tions must  be  carefully  and  cheerfully  obeyed.  Of 
so  great  importance  are  co-operation  and  attention 
to  detail  that  I  no  longer  try  to  cure  these  patients 
against  their  expectation  and  will.  They  must  ac- 
quire a  soul-forwardness  toward  health — every 
thought,  feeling,  and  emotion  must  be  enlisted  in 
the  work. 

Having  secured  the  confidence  and  hearty  co-ope- 
ration of  the  patient,  we  give  minute  directions  as 
to  clothing,  bathing,  rest,  and  exercise.  From  mal- 
nutrition and  auto-infection  the  vaso-motor  centres 
are  weak  and  irritable,  and  paling  of  the  surface 
leads  to  a  corresponding  internal  congestion. 
Hence  the  necessity  for  warm  clothing,  especially 
over  the  abdomen,  to  protect  against  sudden  chan- 
ges or  extremes  of  temperature  and  loss  of  body 
heat.  The  rapidity  and  completeness  of  reaction 
guide  in  the  selection  and  the  mode  of  bathing.  In 
the  beginning  a  warm  plunge  or  sponge  bath  in  a 
warm  room  should  be  advised,  and  the  difference 
between  the  temperature  of  the  air  and  the  water 


90  THB  CAUSATION    AND 

cautiously  increased  from  day  to  day.  The  bath 
Improves  the  function  and  nutrition  of  tin -skin  and 
tones  the  nervous  system.  It  has  been  demon- 
strated that  the  toxicity  Of  tli<-  urine  is  increased 
during  the  administration  of  the  Brand  treatment 
of  typhoid  fever,  and  the  increased  elimination  of 
fcoxines  is  qo1  the  least  of  the  henetits  derived  from 
bathing.  If  the  stools  are  frequent  and  exhausting, 
absolute  rest  in  bed  must  lie  enjoined  ;  during  con- 
valescence moderate  exercise  and  fresh  air  will  has- 
ten the  cure.  Overfatigue,  mental  and  physical, 
must  be  scrupulously  avoided,  temperance  and 
moderation  being  the  guide0  of  conduct.  The  mode 
Of  life  must  he  put  on  a  physiological  basis  and  .is 
much  energy  and  vitality  conserved  as  possible. 

The  curative  treatment  of  a  chronic  diariboal 
disease  has  very  little  to  do  with  the  control  of  the 
symptom  by  the  use  of  opiates  and  astringents  ;  Ave 
must  go  behind  the  lesion  of  the  mucous  membrane 
and  strike  boldly  ;it  causation.  Behind  the  veil  a  re 
the  hidden  forces  at  work,  beneath  the  surface  are 
the  sources  of  evil.  It  is  a  waste  of  time  to  strike 
at  the  shadow;  it  is  useless  to  close  the  volcano's 
mouth  while  the  subterranean  fires  are  still  burn- 
ing. The  curative  treatment  of  a  chronic  diarrhoea 
must  be  aetiological. 

Active  elimination  by  all  of  the emunctories is  also 
a  sheet  anchor  in  the  treatment  of  chronic  diarrhoa. 
Free  drainage  is  the  first  law  of  surgery,  and  free 
drainage  is  a  controlling  principle  in  the  treatment 
of  a  chronic  disease  accompanied  by  or  resulting 
from  auto-infection.  We  have  already  seen  that  a 
chronic  diarrhoea  is  largely  a  conservative  process, 


TREATMENT   OF   CHRONIC    DIARRHOEA.  91 

;in<l  is  just  as  essential  as  the  drainage  of  ;>  septic 
wound.     Checking  a  chronic  diarrhoea  by  astrin 
gents  and  drugs  that  paralyze  muscular  movement 

before  the  digestive  tube  is  made  clean  and  sweet. 
can  only  produce  a  violent  explosion  which  will 
widen  old  rents  or  find  new  points  of  exil  where 
resistance  is  weakest.  So  great  is  the  danger  of 
auto-infection  from  the  alimentary  canal  that  Na- 
ture has  well  barricaded  the  system  against  inv,i 
sion  from  this  quarter.  An  active  peristalsis  tjp  di- 
vert the  enemy,  mesenteric  glands  and  the  liver  to 
arrest  and  destroy,  oxidation  to  burn,  the  skin, 
kidneys,  and  liver  to  turn  aside  or  sweep  away— 
these  are  the  strong  barriers  which  our  treatment 
must  support  and  strengthen.  Impaired  digestion, 
defective  absorption,  malassimilation,  auto-infec- 
tion, are  heavy  blows  against  nutrition.  To  build 
up  the  blood  so  that  it  may  perform  its  work  is 
a  controlling  object.  Healthy  nutrition  is  a  hope 
that  only  careful  alimentation  can  realize.  These 
are  the  important  general  considerations  :  on  the 
one  hand  the  bright  side  of  the  shield,  a  well-fit- 
ting armor,  a  determination  to  conquer,  and  on  the 
other  the  removal  of  the  cause,  careful  alimenta- 
tion, and  active  elimination. 

Of  no  less  importance  are  the  local  indications  : 
1.  To  cleanse  the  alimentary  canal  and  keep  its  con- 
tents sweet.  2.  To  secure  perfect  digestion  of  the 
food  taken.  3.  To  promote  absorption.  4.  To  di- 
minish the  work  of  the  diseased  part.  5.  To  treat 
the  lesions,  6.  To  treat  the  sequela?.  7.  To  con- 
trol the  harmful  symptoms. 

Our  first  object  is  to  cleanse  the  alimentary  canal, 


!•■.'  THE   CAUSATION     \  SD 

and  cholagogues  ami  purgatives  will  render  efficienl 
service iD  its  accouiplishmeiit.     An  increased  flow 
of  healthy  bile  will  meet  more  ilian  one  indication 
it   is  not   irritating,  is  Laxative,  and  also  aids  in 
digestion,  absorption,  and  the  prevention  of  decora 
position.     Podophyllin,  ipecac,  salicylate  of  sodium 
(or,  better,  salicin  and  bicarbonate  of  soda),  and  the 
bichloride  and  biniodide  of  tnercury  arc  the  mosl 
useful  cholagogues.     To  gel  their  selective  action 
on  the  liver  these  drugs  should  begiveniu  minute 
doses.     Small  doses  of  calomel  also  acl  well,  espe 
dally  if  the  kidneys  are  sound,  or  the  heart  dis- 
eased, or  arterial  tension  is  high,  or  the  bile  ducts 
distended.     Cascara  sagrada  is  the  mosl   valuable 
laxative   -it  inriv;is,s  peristalsis  hy  its  act  ion  on  the 
nerve     -apply    of    the    intestine,    washes   out     the 
glands  and  follicles  by  augmenting  their  secretion, 
ami  in  laxative  doses  is  unirritating,  an  important 
negative  quality  thai  often  secures  for  it  prefer- 
ence.    Those  drugs  should  be,  selected  which  least 
irritate  the  diseased  part  ;  too  much  care  cannot  he 
exercised  in  this  respect,  as  these  remedies  cut  both 
ways  ami  can  do  harm  as  well  as  good.      Stomach 
washing  will  also  help  us  to  clean  a  pari  of  the  ali 
mentary  canal.     When  this  important  viscus  is  di- 
lated and  incapable  of  emptying  itself  completely, 
when  the  muscular  movement  is  defective  and  the 
food  is   fermenting,   decomposing,   or   undergoing 
superdigestion,  the  procedure  is  a  valuable  one,  hnt 
must  not  he  repeated  too  frequently.     But  when 
not  dilated,  and   strong  enough  to  empty  itself,  the 

stomach  can  be  efficiently  ami  agreeably  washed 
out  by  copious  draughts  of  hot  water.     Hot  water 


TREATMENT   OP   CHRONIC    DIARRHGCA.  93 

is  also  a  powerful  hepatic  stimulant,  Liquefies  iln- 
hile,  and  washes  out  the  Liver,  which  is  often  in 
fected  from  a  septic,  duodenum  or  through  the  por 
tal  vein  or  hepatic  artery.  The  liver  is  the  greal 
ccniral  depot  tor  the,  arrest,  destruction,  and  elimi 
nation  of  toxic  material,  and  the  entero-hepatic 
circulation  should  he  frequently  flushed  out.  Hot 
water  does  this  very  rapidly  and  efficiently.  The 
large  bowel  is  the  seat  par  excellence  of  fermenta- 
tion and  putrefaction,  and  the  most  frequent  source 
of  auto-infection.  It  can  he  thoroughly  washed 
out  with  warm  or  cold  water,  to  which  an  alkali 
should  he  added  if  there  be  much  mucus  in  the 
stools.  The  use  of  antifermentatives  and  antisep- 
tics is  rendered  necessary  by  the  inefficiency  of 
lavements,  cholagogues,  and  laxatives  to  accom- 
plish our  purpose — the  cleansing  of  the  digestive 
tube.  I  use  only  a  few  of  the  drugs  of  this  class, 
the- ones  that  I  have  found  the  most  efficient — sali- 
cin,  the  biniodide  of  mercury,  salol,  and  the  subni- 
trate  of  bismuth.  Salicin  is  the  best  sweetener  of 
the  stomach,  given  in  ten-  to  twenty-grain  doses, 
two  hours  after  meals,  or  one  hour  before  breakfast 
and  retiring.  The  biniodide  of  mercury  is  valuable 
in  small  doses  when  the  decomposition  is  in  the 
small  bowel,  chiefly  on  account  of  its  action  on  the 
liver.  Salol  is  by  far  the  best  duodenal  antiseptic. 
These  three  drugs  act  locally,  and  also  by  exciting 
a  free  flow  of  the  natural  intestinal  antiseptic — 
healthy  bile.  Cholagogues  spur  onward  the  entero- 
hepatic  circulation,  as  Kosenthal  has  shown  that 
both  bile  and  the  biliary  salts  are  hepatic  stimu- 
lants.    Calomel  is  also  an  antiseptic-,  and  some  aid 


9  t  THE   CAUSA  HON    AND 

is  derived  from  its  passage  along  tin*  intestine. 
Subnitrate  of  bismuth  reaches  fche  Large  bowel,  but 
is  ii"t  of  much  value  unless  given  in  very  large 
doses.  These  drugs  are  very  useful  in  combating 
putridity  and  maintaining  fche  sweet  oess  of  fche  ali 
mentary  canal.  It  has  been  suggested  thai  bacteria 
have  something  to  do  with  digestion  ;  L  gravel] 
suspecl  thai  enough  will  be  left  for  this  purpose 
after  we  bave  exhausted  our  means  in  fche  efforts 
to  exterminate  them. 

It  is  also  important  fco  administer  clean  and  sweel 
food  and  pure  drinking  water.  This  is  a  matter  of 
more  moment  than  fche  little  attention  we  bestow 
upon  it  would  seem  fco  indicate.  How  rapidly  a 
septic  colitis  subsides  when  an  impure  drinking 
water  is  withdrawn  !  How  great  a  change  is  some- 
times wrought  by  forbidding  a  food  that  is  \<«> 
"high"  or  lias  not  been  scientitieally  prepared? 
Attention  to  little  details  like  these  sometimes 
changes  fche  whole  course  of  the  disease. 

Having  secured,  as  nearly  as  we  can,  a  dean  and 
sweet  state  of  the  digestive  tube,  our  next  object  is 
to  get  perfect  digestion  of  the  food  taken.  This  is 
an  aim  second  to  no  other  in  importance.  Undi- 
gested food  in  the  wrong  part  of  the  intestine  is 
an  irritant.  Rapid  absorption  is  the  chief  barrier 
against superdigestion,  fermentation,  and  putrefac- 
tion, and  perfect  digestion  is  the  essential  prelimi 
nary  to  the  easy  and  healthy  performance  of  this 
function  of  the  mucous  membrane.  We  attempt 
to  realize  this  high  aim  by  a  proper  diet,  and  by 
increasing  or  supplementing  whatever  digestive 
juice  we  have  reason  to  suspect  is  defective.     If  th  ■ 


TREATMENT   OF   CHRONIC'    DIARRHOEA.  95 

stomach  is  at  fault  in  its  chemical  work  we  keep 
our  eye  on  the  acidity  of  the  secretion,  for  the  EC! 

is  an  important  and  the  most  frequently  varying 
constituent  of  the  gastric  juice.  The  dilute  EC! 
should  he  given  in  two  or  three  doses  of  live  or  leu 
< I rops  each,  within  two  hours  following  the  meal, 
and  a  small  quantity  of  fresh  pepsin  may  be  added. 
I  suspect  that  a  dose  of  toxines  is  often  given  in 
the  name  of  this  ferment.  In  the  meantime  we 
give  such  drugs  as  are  known  to  increase  or  dimin- 
ish the  acidity  of  the  gastric  juice.  If  the  liver  or 
pancreas  he  at  fault  we  use  the  drugs  that  have  a 
selective  action  on  these  glands,  and  supplement 
with  fresh  bile  and  pancreatin  by  the  mouth.  It 
is  best  to  precede  their  administration  by  an  alkali. 
The  time  of  giving  them  is  two  and  a  half  or  three 
hours  after  meals,  except  on  the  milk  diet,  when 
the  proper  time  is  just  before  each  feeding.  'Duo- 
denal digestion  is  thus  made  to  begin  in  the  sto- 
mach. If  the  muscular  movements  of  the  stomach 
and  intestines  are  defective,  strychnia,  massage, 
and  electricity  will  render  important  aid.  Diar- 
rhoea not  infrequently  has  its  cause  in  localized  de- 
fective peristalsis — the  contents  collecting  in  the 
weak  and  dilated  parts  and  undergoing  putrefac- 
tion, fermentation,  and  hardening.  With  a  clean 
digestive  tube,  the  secretions  and  movements  of 
which  have  been  regulated  and  supplemented,  it 
remains  to  select  a  proper  diet.  This  is  the  most 
difficult  and  most  important  part  of  the  treatment. 
And  here  the  physician  should  dismount  from  his 
"■hobbies'-  and  renounce  so-called  '"fads"  and 
"  cure-alls."     Vegetarianism  will  rarely  fail  to  do  a 


96  'I'll  I :   l    IUSATION     \M> 

good  deal  <>i  harm  ;  the  milk  diel  in  its  many  forms 
is  noi  a  panacea  ;  a  diet  of  animal  food  will  not 
often  fail  t"  benefit,  and  has  a  very  wide  range  of 
usefulness. 

In  selecting  a  diel   wq  have  a  good  many  things 
to  take  into  consideration.    The  evils  of  exclusive 

iics^  .ill  are  ready  to  admit.  In  any  dietary  the 
primary  principles  must  be  made  t<>  preserve  a  cer- 
tain proportion  in  obedience  to  the  laws  of  physio- 
logical chemistry,  and  such  proportion  arbitrarily 
altered  i<>  suit  the  needs  and  capabilil  Les  of  general 
nutrition.  But  laboratory  results  need  to  lie  cor- 
rected  and  controlled  by  the  testimony  of  the  hu- 
man digestive  system.  The  diet  habits  of  mankind 
and  of  the  different  nations  of  the  earth  furnish 
a  rich  store  of  information;  for  man.  when  per- 
mitted to  do  so,  eats  what  most  pleases  the  palate, 
keeps  him  well  nourished  and  strong,  and  gives  the 
Least  after-pain.  Climate,  age,  activity,  peculiari- 
ties, and  the  capability  of  the  digestive  organs  are 
other  important  considerations.  Now,  in  the  diet 
of  a  chronic  diarrhoea  the  food  must  he  chietly 
digested  by  the  stomach,  contain  the  right  propor- 
tion and  proper  quantity  of  proximate  principles 
to  meet  the  requirements  of  secretion,  nutrition, 
and  the  production  of  animal  heat,  and  leave  no  ir- 
ritating or  indigestible  residue.  Denutrition  must 
be  guarded  against,  and  the  diseased  intestine  given 
physiological  rest  and  kept  free  from  irritation.  An 
exclusive  diet  of  milk,  or  a  diet  of  meat  free  from 
fibrous  tissue,  would  fulfil  these  indications — the 
one  more  completely  than  the  other,  perhaps— but 
both    must    be  perfectly   digested.     Milk  is  a  fluid, 


TREATMENT  OF  CHRONIC    DIARRHCEA.  '■>', 

but  becomes  semi-solid  during  digestion.  Meat  is  a 
solid,  but  becomes  a  fluid  in  its  preparation  forab 
sorption.  Milk  may  be  a  little  more  easily  assimi- 
lated, but,  bulk  for  bulk,  is  not  so  nutritions.  The 
final  product  of  the  perfect  digestion  of  the  one  is 
about  as  easily  absorbed  and  unirritating  as  that  of 
the  other.  Both  require  great  care  in  selection 
and  the  meat  must  be  properly  prepared  and 
cooked.  However,  it  is  difficult  to  get,  day  after 
day,  milk  which  is  free  from  pathogenic  bacteria  : 
it  readily  undergoes,  both  in  and  out  of  the  stomach, 
chemical  and  bacterial  changes  with  the  forma- 
tion of  irritating  and  poisonous  products  ;  and  I 
have  found  it  well-nigh  impossible  to  secure  ifs  con- 
tinued perfect  digestion  during  a  period  long  enough 
for  a  cure  to  take  place.  When  the  gastric  juice  is 
hyperacid,  or  duodenal  catarrh  or  portal  congestion 
or  excessive  fermentation  is  present,  milk  will  not 
agree.  The  supreme  test  is  the  one  at  the  bedside. 
In  my  experience  a  meat  diet  is  much  more  valu- 
able, less  dangerous,  and  of  a  much  wider  range  of 
application  than  milk  in  the  treatment  of  chronic 
diarrhoea.  Exclusive  in  the  beginning,  the  meat 
must  be  supplemented  by  bread,  cereals,  and  the 
more  easily  digested  vegetables  in  the  manner  de- 
tailed by  me  in  a  paper  printed  elsewhere  in  this 
book.1  It  is  the  duty  of  the  physician  to  see  that 
whatever  food  be  taken  is  completely  digested  and 
assimilated,  and  he  has  in  the  daily  physical  exami- 
nation of  the  digestive  system,  and  the  analysis  of 
the  urine  and  the  inspection  of  the  stools  as  often 

1  See  clinical  paper  "  On  the  Treatment  of  Functional  and  Catar- 
rhal Diseases  of  the  Stomach  and  Bowels,"  Appendix,  p.  113. 
7 


THE  CAUSATION     \N!> 

as  may  be  necessary  (aided,  if  needed,  by  the  micro- 
scope), a  pretty  sure  guide.  It'  the  patient  feels  no 
pain  nor  discomfort  nor  drowsiness  after  meals,  if 
there  is  no  flatulence,  if  tin  mine  contains  no  al> 
normal  coloring  matter  nor  excess  of  phosphates, 
orates,  or  uric  acid,  and  the  Btools  contain  no  undi- 
gested products,  we  know  thai  the  food  is  being 
digested  and  assimilated,  and.  if  there  be  no  Loss  of 
strength,  absorbed  in  sufficient  quantity  to  meet  the 
demands  of  life. 

To  avoid  denutrition  is  not  alone  requisite:  the 
barriers  musi  be  made  strong;  the  body  must  be 
protected  and  defended  and  built  up.     Not  only  a 

pure  and  adequate  hut   also  a   rich  blood  is  needed. 
And  the  quality  of  the  blood,  its  gain  or  I"--  of 
richness  from  day  to  day.  can  be  detected  by  count 
ing  the  corpuscles  and  measuring  the  haemoglobin. 
No  physician  would  now  assume  the  management 
of  a  disease  of  the  heart  <>r  lungs  without  the  evi 
deuce  and  guidance  of  physical  signs.     No  physi 
cian  should  now  attempt  to  diagnosticate  or  treat  a 
disease  of  nutrition  without  a  study  of  the  blood 
and  excretions. 

When  we  have  an  alimentary  canal  clean  and 
sweet,  and  the  lining  washed  free  from  mucus,  con 
t  a  ining  a  completely  digested  and  uninilai  ing  fluid, 
much  has  already  been  done  to  promote  absorption. 
An  active  entero-hepatic  circulation  and  the  control 
of  excessive  peristalsis  Bhould  complete  the  work. 
The  relief  of  portal  engorgement  and  the  slhnn 
Lating  of  the  liver  will  aid  the  one,  while  the  re 
moval  of  local  irritation  and  the  quieting  of  the 
nerve  endings  and  centres,   and  the  strengthening 


TREATMENT  OF   CHRONIC    DIARRHCEA.  98 

of  them  by  active  elimination  and  improved  nutri- 
tion,'hav.e  done  much  to  realize  the  other.  These 
are  the  curative  means,  hut  it  is  often  necessary 
to  control  excessive  peristalsis  in  order  to  keep  the 
contents  in  contact  with  the  mucous  membrane 
long  enough  for  absorption.  Antacids,  bismuth, 
and  antispasmodics  should  housed  instead  of  opium 
and  narcotics.  The  control  of  flatulence  also  in- 
creases the  absorptive  surface. 

The  value  of  rest  in  the  treatment  of  a  disordered 
or  inflamed  part  cannot  he  overestimated.  .Repair 
is  more  complete,  healing  goes  on  more  rapidly. 
An  exudation  in  the  process  of  organization  is  easily 
broken  up  by  movement.  Absolute  rest  of  a  dis- 
eased intestine  cannot  be  attained  without  stopping 
drainage,  but  a  great  deal  can  be  done  by  keeping 
the  part  free  from  irritants,  and  by  the  use  of  drugs 
that  will  lessen  the  exaggerated  irritability,  that 
will  quiet  the  pathological  unrest.  The  diet  should 
also  be  selected  so  as  to  diminish  the  work  of  the 
diseased  part.  When  the  duodenum  is  the  centre 
( >f  disturbance  (as  it  often  is)  the  stomach  must  be 
made  to  do  the  work.  When  the  disease  is  lower 
down  the  diet  must  be  such  as  is  quickly  digested 
and  rapidly  absorbed,  and  excessive  peristalsis  con- 
trolled. When  the  stomach  and  duodenum  are 
able  to  do  their  work  well,  and  the  disease  is  in  the 
colon  only  or  low  down  in  the  ileum,  a  milk  diet,  if 
it  agree,  is  superior  to  any  other. 

In  the  severe  cases  of  chronic  diarrhoea,  when  the 
muscular  layer  is  atrophied  or  cedematous,  or  infil- 
trated with  inflammatory  products,  constipation  is 
very  apt  to  supervene  as  soon  as  irritation  is  re- 


Id"  THE   CAUS  LTION    A\i> 

moved.  1  would  like  to  emphasize  this  important 
clinical  fact  thai  these  weak  points  in  the  intes- 
tinal wall  are  often  Localized,  and  the  obstruction 
in  tli«'  drain  must  be  overcome  by  massage,  laxa- 
tives, and  lavements.  To  clear  oul  these  depots  of 
fermentation  and  putrefaction  Is  an  essential  pari 
of  the  treatment ;  until  this  is  done  there  can  be  no 
rest,  no  healing. 

The  indications  afforded  by  the  Lesions  have  been 
partly  me1  by  cleanliness,  rest,  and  the  prevention 
of  irritation.  If  the  lesion  be  syphilitic,  specific 
treatment  must  not  be  neglected.  When  situated 
in  the  Large  bowel  something  may  be  accomplished 
by  medicated  Lavements. 

The  treatment  of  the  sequelae  resolves  itself  into 
the  treatment  of  atrophy  and  deformity-  the  re 
suits  of  degeneration  and  destructive  inflammation. 
A  proper  diet  and  a  regulated  Life  will  aid  Nature  in 
the  readjustment  of  the  organism  to  the  changed 
conditions.  The  deformity  may  demand  the  sur- 
geon's skill. 

The  special  and  general  treatment  of  chronic 
diarrhoea  must  often  lie  modified  or  supplemented 
by  the  treatment  of  the  causative  disease. 

In  conclusion,  the  indications  for  the  treatment 
of  chronic  diarrhoea  may  he  thus  briefly  stated  : 
1.  To  remove  or  treat  the  cause,  which  presupposes 
iis  detection.  2.  To  improve  nutrition  and  conserve 
energy.  3.  To  secure  active  elimination  and  pre- 
vent auto-infection.  4.  To  cleanse  the  alimentary 
'anal  and  keep  its  contents  sweet.  5.  To  secure 
perfect  digestion  of  the  food  taken.  <>.  To  promote 
absorption.      7.   To  diminish   the    work    of  the  dis- 


TREATMENT  OP  CHRONIC    DIARRHOEA.  L01 

eased  part.  8.  To  treat  the  lesions.  9.  To  treai 
tlie  sequoia;,  lo.  To  control  the  harmful  symp 
torus. 

A  broad  and  comprehensive  and  a'tiological  treat- 
ment, and  one  which  I  have  found  successful — a 
union  of  many  powers  which  make  for  health,  a 
union  in  which  "all  are  needed  by  each  one."  It 
is  not  sufficient  to  meet  the  controlling  indications, 
but  regulations  must  descend  into  minute  details. 
The  moral  management  of  the  patient  has  a  power- 
ful and  practical  bearing.  Two  important  elements 
of  success  are  individualization  and  the  persistent 
doggedness  with  which  one  enforces  right  living. 
The  prescription  of  drugs  is  a  very  small  part  of  the 
work  which  we  have  to  do.  The  chief  aim,  the 
definite  therapeutic  purpose,  is  to  secure  healthy 
nutrition  by  careful  alimentation,  perfect  digestion, 
and  complete  elimination,  thus  keeping  in  active 
circulation  a  pure  and  rich  nutritive  fluid.  In  no 
other  way  can  we  control  and  strengthen  cell  life 
than  by  placing  it  in  the  best  environment  and  ob- 
taining the  substitution  of  new  protoplasm  for  that 
which  is  old  and  diseased.  This  is  the  basis  of  cure, 
the  grand  purpose  which  gives  unity  and  system  to 
the  management. 


CHAPTER  V. 

THE  CURATIVE   TREATMENT   OF    HABITUAL 
CONSTIPATION. 

Habitual  constipation,  as  it  will  be  considered  h\ 
this  short  chapter,  may  be  defined  as  chronic  inade- 
quate intestinal  peristalsis.  The  defect  is  a  purely 
neuromuscular  one,  and  must  be  carefully  differ- 
•  utiated  from  cases  in  which  there  is  more  or  less 
stasis  and  retention  of  the  intestinal  contents  from 
obstruction.  Here  it  is  not  inefficient  peristalsis, 
but  the  obstruction,  whatever  be  its  nature,  that  is 
the  disease. 

Peristalsis  is  normally  under  the  control  of  the 
nervous  system  through  the  reflex  stimulus  of  the 
intestinal  contents,  and  consequently  there  are  three 
ways  in  which  the  disorder  maybe  produced — by 
defect  on  the  part  of  the  nervous  system,  or  of  the 
muscular  layer,  or  of  the  peripheral  excitation  <>l 
the  sensory  nerves  of  the  mucous  membrane.  Now, 
the  one  fact,  on  which  a  good  deal  of  what  follow  s 
will  be  based,  is  that  the  normal  stimulus  of  intes- 
tinal peristalsis  is  the  unabsorbed  product  of  healthy 
digestion,  and,  consequently,  when  there  is  no  pri- 
mary neuromuscular  defect  we  must  look  for  the 
origin  of  the  trouble  in  indigestion,  defective  secre- 
tion, or  in  the  quantity  or  quality  of  the  food  and 
drinks. 


TREATMENT   OF    HABITUAL   CONSTIPATION.         L03 

The  physical  properties  of  the  intestinal  contents 
depend  on  the  nature  of  the  diet,  the  quantity  of 
fluid  swallowed,  and  the  rapidity  of  absorption  and 
elimination.  In  polyuria,  and  when  too  little  water 
is  drunk,  the  faeces  quickly  become  hard  and  dry. 
Absorption  from  the  stomach  and  the  duodenum  is 
not  very  great  as  compared  with  its  activity  lower 
down  in  the  small  intestine  and  in  the  colon.  A 
diet  containing  a  large  quantity  of  indigestible  mat- 
ter will  prove  to  be  mechanically  too  irritating.  An 
abuse  of  starches  is  the  most  common  cause  of  dis- 
ordered peristalsis  depending  on  the  nature  of  the 
diet.  It  has  been  demonstrated  on  a  grand  scale 
that  the  starchy  army  diet  produced  either  diarrhoea 
or  constipation.  And  it  has  been  conclusively 
proven  that  when  fatigue,  irregular  habits,  and 
unsanitary  surroundings  are  excluded,  a  diet  of 
starches,  in  healthy  men,  causes  constipation  and 
diarrhoea.  Severe  irritation  sets  up  diarrhoea. 
Mild,  long-continued  irritation  will  just  as  surely 
establish  constipation.  The  mucous  membrane  be- 
comes too  tolerant. 

Habitual  constipation  may  be  either  the  cause  or 
the  result  of  disordered  digestion.  We  have  already 
seen  in  the  preceding  chapters  how  intimately  as- 
sociated are  the  chemical  and  motor  functions  of 
the  digestive  tube.  The  digestive  changes  that  the 
food  undergoes  are  about  finished  at  the  ileo-caecal 
valve.  The  chemical  alteration  of  the  food  mass  in 
the  colon  is  chiefly  due  to  organic  fermentation  and 
decomposition,  and,  by  a  beautiful  provision,  nature 
has  made  these  decomposition  products  (scatol, 
H3S    and  C02)  the  active  exciters  of  peristalsis. 


I"  I  THE  CURATIVE   TREATMEK  I 

But,  union  unately,  these  substances  are  more  or  Less 
poisonous,  and  when  nol  expelled  undergo  absorp- 
tion along  with  abnormal  products,  and  coprsemia 
with  its  restlessness,  giddiness,  insomnia,  pains  and 
mental  depression,  anaemia,  chlorosis,  palpitation, 
cold  hands  and  feet,  and  digestive  disturbances, 
results.  A.uto-infection  disorders  digestion,  de- 
ranges the  nervous  system,  and  lowers  nutrition. 
It  is  thus  thai  the  vicious  circle  is  established  and 
continues  its  unceasing  revolutions.  The  constipa- 
tion results  from  the  diminished  sensibility  which 
follows  the  chronic  irritation  or  inflammation  or 
distention  produced  by  the  imperfectly  digested  and 
decomposing  and  fermenting  food  mass.  In  the 
same  way  constipation  originates  in  the  abuse  of 
purgatives  and  neglect  of  the  normal  promptings 
of  nature  It  is  the  pill-taking  American,  and  mod- 
est woman,  and  husy  or  lazy  or  negligent  man  who 
most  often  contract  the  habit  in  this  way.  WTien 
the  call  to  stool  is  unanswered  the  faecal  matter  is 
either  regurgitated  by  reversed  peristalsis  into  the 
sigmoid  flexure,  or  accumulates  unheeded  in  the 
tolerant  rectum  to  undergo  hardening  by  absorp 
fcion.  Thus  is  the  unhealthy  variation  established 
by  had  habits  and  unphysiological  living. 

We  have  already  considered  the  relation  of  neu- 
rasthenia to  the  neuromuscular  form  of  dyspepsia. 
Peristalsis  and  tonicity  are  inadequate,  because 
too  little  nerve  power  is  radiated  out  to  the  mus 
cular  system.  There  is  a  lack  of  muscular  power, 
and  a  lack  of  muscular  tone  develops  from  dis 
use.  It  matters  not  what  may  be  the  disease  of 
which    the   neurasthenia    is    the    symptom,   or    the 


OP    HABITUAL   <  ONSTI  IWTloN.  L05 

nature  of  the  cause— emotive  shock,  overwork, 
traumatism,  or  malnutrition  of  which  it  is  the 
result.  The  lowered  nerve  lone,  the  nerve  weak- 
ness, is  the  cause  of  the  diminished  vitality  and 
denutrition  of  the  muscular  layer  and  the  inade 
(mate  peristaltic  power.  The  neuromuscular  in- 
sufficiency is  so  often  associated  in  families  as  to 
suggest  the  influence  of  heredity  ;  but,  while  not 
prepared  to  deny  the  possibility  of  the  inheritance 
of  the  specialized  defect  of  constitution — it  being 
well  known  that  unhealthy  variations  are  trans- 
mitted with  the  same  certainty  as  are  the  useful 
ones — it  seems  more  plausible  to  suspect  that  the 
vice  which  arrogance  is  wont  to  attribute  to  the 
sins  of  another  is  nearly  always  acquired  by  bad 
habits,  a  faulty  environment,  and  unhealthy  living. 
Infectious  and  mineral  poisons  like  lead  seem  to 
produce  constipation  by  their  influence  on  the  nerve 
supply.  Chronic  diseases  of  the  brain  and  spinal 
cord  are  also  accompanied  by  obstinate  constipa- 
tion. 

The  cerebro-spinal  and  ganglionic  nerves  may  be 
efficient  in  the  performance  of  their  work,  and  con- 
stipation result  from  atony,  or  degeneration,  or 
atrophy,  or  oedema  of  the  muscular  layer.  Here 
the  disorder  has  a  muscular  and  not  a  neural  basis. 
A  weak  diaphragm  and  flaccid  abdominal  wall  and 
general  muscular  flabbiness  are  commonly  associ- 
ated with  the  atonicity  of  the  muscular  layer.  The 
inactive  centres  of  old  age  go  along  with  the  athe- 
roma and  fatty  degeneration  and  weak  involun- 
tary muscles.  But  more  frequently  the  muscular 
inadequacy  is  the  accompaniment  or  legacy  of  a 


Hit;  THE   I  tka  Tl\  i:    rREATMENT 

diseased  mucous  membrane,  peritonitis,  or  malnu- 
trition iron  i  the  distention  of  gases,  or  the  pressure 
of  accumulated  and  hardened  faeces ;  or  the  oedema 
of  heart  disease,  or  portal  obstruction,  or  Blight's 

disease,  or  of  a  watery  blood. 

Habitual  constipation  is  without  urgent  distn 
it  is  slow  in  its  destructive  work    and   insidious   in 

undermining  the  general  health.  But  intestinal  ob- 
struction is  not  rarely  engrafted  on  habitual  con- 
stipation, and  whenever  it  supervenes  the  symp- 
toms atonce become  severe.    The  condition  is  no 

longer  simply  a  disturbing   but  a  deadly  one.     It 

becomes,  then,  our  duty,  before  a  prognosis  can  be 

given  and  a  rational  treatment  adopted,  to  differen- 
tiate chronic  inadequate  intestinal  peristalsis  and 
chronic  constipation  accompanying  other  diseases 
and  conditions  ;  to  differentiate  l.eeal  impaction  se- 
quential to  habitual  constipation  and  faecal  impac- 
tion or  stasis  due  to  the  intestinal  paralysis  of  peri- 
tonitis, the  caeca!  paresis  of  appendicitis,  and  com- 
plete obsl  met  ion  produced  by  other  causes. 

Chronic  constipation  is  a  frequent  symptom  of  a 
diseased  rectum  or  anus.  It  is  advisable,  in  search- 
ing for  the  cause  of  the  constipation  with  a  view  to 
arriving  at  a  correct  diagnosis  on  which  to  base  an 
opinion  and  palliative  or  curative  treatment,  t<> 
make  a  careful  rectal  examination.  When  pain 
accompanies  and  follows  defecation  this  examina- 
tion is  imperative.  An  ulcer,  or  a  fissure,  or  a  blind 
or  complete  fistula,  or  a  sensitive  pile,  or  an  irritable 
and  powerful  sphincter,  will  frequently  be  found 
the  disease;  which  demands  treatment.      The  fissure 

I 

or  ulcer  or  hemorrhoid  may  be  the  result  of  the 


OF   HABITUAL  CONSTIPATION.  L(W 

constipation,  in  which  case  the  neuromuscular  dis- 
order will  persist  after  the  cure  of  the  Local  trouble. 
An  eczema  in  the  region  of  the  anus  (frequent  in 
infancy)  becomes  a  common  cause  of  constipation 
through  voluntary  or  reflex  inhibition  of  defeca- 
tion. The  little  child  strives  to  prevent  the  suffer- 
ing associated  with  the  act.  It  is  through  frequent 
voluntary  resistance  that  the  sphincter  is  overde- 
veloped and  the  rectum  made  tolerant.  Excessive 
hypertrophy  of  the  body  of  the  uterus,  or  a  retro- 
verted  or  retroflexed  uterus,  may  be  another  cause 
of  constipation. 

Chronic  intestinal  obstruction  must  be  estab- 
lished as  the  cause  of  the  chronic  constipation  by 
the  sequence  of  symptoms  as  revealed  in  the  clini- 
cal history,  by  the  detection  of  the  causative  lesion, 
and  by  the  presence  of  additional  symptoms  to 
those  ordinarily  produced  by  habitual  constipation. 
Very  large  and  foul  movements  should  excite  sus- 
picion. Habitual  constipation  is  temporarily  and 
painlessly  relieved  by  the  proper  dose  of  a  purga- 
tive, which  would  excite  colicky  pains  above  the 
site  of  obstruction.  The  mode  of  origin  is  of  more 
importance  than  the  symptoms.  Previous  severe 
inflammation  would  suggest  bands  or  adhesions  or 
constricting  organized  fibrous  tissue.  Ulceration  is 
a  common  cause  of  stricture.  Acute  intussuscep- 
tion, ending  in  recovery  by  the  formation  of  adhe- 
sions and  the  separation  and  discharge  of  the  in- 
carcerated part  of  the  bowel,  may  be  followed  by 
chronic  obstruction.  The  intestine  just  above  the 
obstructed  point  hypertrophies  ;  peristalsis  and 
thickening  may  be  seen  and   felt  ;  dilatation  may 


Ins  THE   CURATIVE   TREATMENT 

alter  the  configuration  of  the  abdomen.     The  form 
of  the  faecal  discharge  may  be  important  if  piles 

art-  absent,  or  the  prostate  is  not  enlarged,  or  the 
uterus  is  movable  and  in  its  normal  position.  The 
trouble  may  be  revealed  by  the  finger  or  the  rec 
tal  bougie,  or  by  filling  the  colon  with  water  or  by 
inflating  it  with  air.  It  is  not  always  possible  to 
form  a  definite  conclusion  after  the  mosl  careful 
and  exhaustive  study. 

Obstruction  by  faecal  impaction,  or  the  complete 
and  insuperable  stasis  of  tin-  intestinal  contents,  as 
a  sequence  of  habital  constipation,  is  usually  located 
in  one  of  the  flexures  of  the  colon  or  in  the  caecum. 
It  is  more  f requenl  in  women.  A  history  of  long- 
continued  constipation  becoming  more  and  more 
obstinate,  the  slight  tenderness  over  a  faecal  tumor 
which  can  be  felt  and  indented,  are  the  diagnostic 
signs.  The  normal  temperature,  the  marked  abdo 
minal  distention  without  tenderness,  the  late  occur- 
rence of  vomiting  which  is  almost  oever  faecal,  the 
extreme  foulness  of  the  breath,  the  increasing  rap- 
idity of  the  pulse  and  the  gradual  exhaustion- by 
chronic  shock  and  inanition,  and  the  fact  that  the 
acute  symptoms  followed  the  administration  of  ,i 
purgative,  aid  in  the  differentiation  from  the  impac- 
tion of  mechanical  obstruction  as  well  .is  the  impac- 
tion produced  by  local  intestinal  paralysis. 

The  cardinal  symptoms  of  obstruction  a] id  st  ran 
gulation  are  the  same — abdominal  pain,  vomiting. 
and  obstinate  constipation  ;  but  strangulation  is 
acute,  the  onset  is  sudden  without  premonitory 
signs,  collapse  is  early,  an  external  strangulated 
hernia  mav  be  detected    or  a   histoiv   of  abdominal 


OF    HABITUAL   OONBTIPATION.  I')'.» 

injury- obtained,  a  little  bloody  serum  and  mucus 
may  be  passed,  and  the  urine  contains  albumin 
rather  than  indican. 

Faval  impaction  located  in  the  CSBCUm  is  both  a 
cause  and  a  result  of  appendicitis.  Primary  appen- 
dicitis and  peri  appendicitis  do  not  seem  much  more 
frequent  than  primary  salpingitis  and  local  peritoni- 
tis. The  analogy  between  tubal  disease  and  disease 
of  the  appendix  is  close  enough  to  be  instructive. 
Perityphlitis  and  abscess  are  about  as  rare  as  pel- 
vic cellulitis  and  pelvic  abscess.  Typhlitis,  on  close 
study,  will  not  be  found  much  less  frequent  than 
endometritis.  Pelvic  peritonitis  without  tubal  dis- 
ease is  as  rare  as  localized  peritonitis  in  the  right 
iliac  fossa  that  is  not  caused  by  a  diseased  appendix. 
In  both  we  get  closure  or  obstruction  of  the  mouth, 
and  accumulation  of  the  secretions,  and  tubal  or  ap- 
pendicular colic.  The  lumen  of  either  tube  may  be 
the  site  of  stricture.  Sepsis  may  extend  from  the 
endometrium  or  from  the  mucous  lining  of  the  cae- 
cum.  Purulent  inflammation  may  travel  in  the 
same  way.  Pyosalpinx  has  its  analogue  in  the  ac- 
cumulation of  pus  in  the  appendix.  Chronic  recur- 
rent appendicitis  is  as  difficult  to  cure  without  re- 
moval as  chronic  catarrhal  or  productive  salpingitis. 
The  analogy  serves  a  useful  purpose  in  emphasizing 
the  aetiological  relation  of  faecal  impaction  of  the 
caecum  and  typhlitis  to  appendicitis.  Dilatation  or 
distention  of  the  caecum  may  also  open  the  mouth 
of  the  appendix  and  permit  foreign  bodies,  winch 
may  become  incarcerated  and  produce  ulceration 
and  perforation  or  gangrene,  to  enter.  The  caecal 
paresis  and  faecal  accumulation  associated  with  ap- 


1  in  THE  CURATIVE    I  RE  \  IMI'.N  C 

pendicitis,  and  produced  reflexly  or  by  contiguity  of 
tli»'  inflammation  in  and  around  the  appendix,  is  ac- 
companied by  fever.  When  the  appendix  is  Bound 
fever  is  usually  absent,  since  perityphlitis  and  Local 
peritonitis  are  so  rare  without  appendicitis  as  to  be 
almost  excluded  from  consideration.  The  differen- 
tiation of  the  caeca!  accumulation  sequential  to  hab 
itual  constipation  and  producing  appendicitis,  from 
the  accumulation  of  faeces  in  the  caecum  resulting 
from  peri-appendicitis,  cannot  be  made  in  the  dim 
light  turned  on  by  the  clinical  history  and  the  phy- 
sical signs. 

The  curative  treatment  of  habitual  constipation 
is  comprised  in  four  special  indications  of  command- 
ing importance  : 

1.  To  set  uie  perfect  digestion. 

2.  To  tone  the  nervous  system. 

3.  To  strengthen  the  muscular  layer. 

4.  To  attend  to  the  hygiene  of  defecation. 

To  correct  the  special  defect,  to  establish  normal 
and  adequate  peristalsis  as  the  habit  of  life  by 
obeying  the  laws  that  condition  it,  is  to  make  the 
basis  and  purpose  of  treatment  rational  and  cura- 
tive. 

A  popular  way  of  curing  habitual  constipation  is 
to  prescribe  an  indigestible  diet  and  force  it  through 
with  a  purgative.  Such  treatment  is  irrational, 
harmful,  and  never  cures,  but  produces  a  tempo- 
rary and  deceptive  improvement.  Excessive  irrita- 
tion need  not  be  expected  to  yield  a  very  brilliant 
result  when  chronic  irritation  has  been  the  cause  of 
the  trouble.  The  worst  kind  of  a  laxative  is  un- 
digested food  undergoing  organic  fermentation  and 


OF    IIA  KIT!   A  I,   CONSTIPATION.  I  I  I 

decomposition,  and  it  docs  not  seem  to  be  a  rery 
good  plan  to  derange  the  stomach  and  duodenum 
in  ordor  to  make  the  colon  empty  itself.  Artificial 
indigestion  is  not  a  cure  Cor  habitual  constipation. 

The  needs  of  general  nutrition  and  the  capability 
of  the  digestive  organs  are  the  guides  in  the  selec 
tion  of  the  diet.  The  method  of  securing  perfect 
digestion  has  already  been  fully  discussed.  The 
quantity  of  fasces  passed  varies  with  the  nature  of 
the  diet,  the  completeness  of  digestion,  the  activity 
of  absorption  and  secretion,  and  the  rapidity  of 
peristalsis.  When  digestion  and  absorption  are 
good  and  the  food  is  digestible,  the  patient  must 
not  resort  to  the  pill  box,  because  a  stool  that  ana- 
lysis proves  to  be  normal  in  composition  is  small. 

The  drinking  of  too  little  fluid  is  a  common  cause 
of  habitual  constipation.  Purgative  and  laxative 
mineral  waters  are  constipating  in  their  after-ef- 
fects. Cold  water  increases  tonicity.  Hot  water, 
as  is  well -known,  is  an  active  exciter  of  peristalsis. 
The  urine  should  be  kept  at  about  1.014-  specific 
gravity,  and  the  stools  soft  by  abundant  drinks  and 
active  intestinal  secretion. 

The  constitutional  measures  and  drugs  for  the 
improvement  of  secretion  and  motility  have  already 
been  considered.  To  tone  and  strengthen  the  neuro- 
muscular element,  massage,  electricity,  and  strych- 
nine are  the  most  useful  remedies.  The  accessory 
muscles  of  defecation  should  also  receive  attention. 

The  healthy  stimulus  of  a  normal  digestive  pro- 
duct and  adequate  neuromuscular  power  should  be 
supplemented  by  regular  habits.  The  unhealthy 
variation  often  originates  in  negligence,  voluntary 


11*3         ri;i;  \i\n.\  I    OF    HABITUAL   CONSTIPATION, 

resistance,   and    irregularity.     Frequent    infraction 

of  tin'  laws  of  health  is  an  influential  factor  in  the 
causation  of  chronic  disorders ;  physiological  Living 
i--  a  |i«>w erful  remedy  in  their  cure. 

The  materia  medica  supplies  us  with  two  drugs 
which,  when  rightly  used,  exeri  a  curative  influ 
ence  in  habitual  constipation  -aloin  and  cascara 
sagrada.  Purgative  doses  do  only  harm.  Aloes  in 
large  doses  produces  griping  pains,  congests  all  the 
pelvic  viscera,  ami  causes  albuminuria.  In  small 
doses  it  is  tonic,  a  mild  cholagogue,  non-irritating, 
and  increases  secretion  and  peristalsis.  Its  valu 
able  selective  and  stimulant  action  on  the  muscular 
layer  of  the  colon  and  rectum,  without  irritating  the 
mucosa,  make-  it  ;i  valuable  curative  drug.  It  i- 
not  followed  by  constipation,  and  its  long-continued 
administration  docs  not  lead  to  the  formation  of  a 

pill  habit.     Aloin.  one-tenth  I te-fifth  grain,  i- 

better  than  the  crude  drug  and  may  be  combined 
with  ipecac,  mix  vomica,  or  a  bitter  tonic,  as  may 
he  indicated. 

Cascara  sagrada  is  a  valuable  laxative  with  cura- 
tive properties.  It  tones  and  increases  peristalsis 
and  intestinal  secretion,  and  is  a  general  tonic  with 
a  selective  influence  on  the  sympathetic  system. 
The  curative  properties  are  also  only  manifested 
whengiyen  in  small  doses  short  of  a  laxative  effect. 

Purgatives,  injections,  suppositories  of  glycerin, 
etc.,  and  other  symptomatic  remedies,  do  not  come 
up  for  consideration  in  the  curative  treatment, 
which  is  comprised  in  good  digestion,  the  hygiene 
of  defecation,  physiological  living,  and  the  strength- 
ening of  the  neuromuscular  layer. 


APPENDIX. 


A   Clinical  Paper  on  the  Treatment  of  Func- 
tional and  Catarrhal  Diseases  of 
the  Stomach  and  Bowels. 

The  purpose  of  this  paper  is  to  present  the  essen- 
tial features  of  certain  methods  of  treatment  which 
I  have  found  to  be  very  useful.  I  shall  endeavor  to 
state  them  in  a  distinctly  clinical  manner,  so  as  to 
show  their  practical  application.  It  will  be  impos- 
sible to  so  enunciate  them  as  to  fit  all  cases,  but  I 
hope  to  convey  an  idea  of  measures  that  can  be  ad- 
justed as  they  are  needed.  There  is  such  a  vast 
range  between  a  functional  derangement  and  an  old 
chronic  gastro-intestinal  catarrh  that  no  system  of 
set  rules  can  be  made  for  uniform  application.  Ac- 
cordingly, much  will  remain  to  be  done  in  the  way 
of  wise  adaptation  by  the  good  sense  and  skill  of 
the  physician.  It  is  hoped,  however,  that  the 
methods  here  outlined  will  prove  to  be  generally  ap- 
plicable and  of  great  service  in  one  of  the  widest 
fields  of  practical  work. 

The  first  step  in  the  treatment  of  functional  and 
catarrhal  diseases  of-  the  stomach  and  bowels, 
whether  moderate  or  severe,  is  to  obtain  full  con- 


Ill  riNiTliiNAL    AND    CATAKltllAL    DISEASES 

trol  of  the  mental  condition  of  the  patient.  Too 
much  emphasis  cannot  be  put  on  iliis  point,  as  fail- 
ure here  is  sure  to  mean  failure  in  the  future.  If* 
there  is  a  mental  antagonism  on  the  part  of  the  pa 
i  i.'n f  to  what  the  physician  is  attempting  to  do ;  if 
there  is  a  lack  of  faith  and  willing  co-operation;  if 
tliciv  is,  from  first  to  last,  a  sort  of  send  indiffer 
ence  and  resistance  then  all  treatment,  no  matter 
how  judiciously  advised  and  how  worthily  applied, 
is  almost  sure  to  result  in  failure.  On  the  conl  rary, 
if  the  physician  first  obtains  the  confidence  and  re- 
Epect  of  his  patient,  secures  his  cheerful  submission 
to  all  instructions  and  requirements,  and  lias  liis 
glad  and  hearty  endeavor  to  help  bring  about  a 
cure,  then  the  principles  and  methods  I  am  about  to 
offer  are  almost  absolutely  sure  to  result  favorably. 
even  in  the  worst  of  cases.  All  this  can  be  done  by 
patience  and  tact,  and  it  is  of  first  importance  lo- 
calise of  that  close  relation  existing  between  the 
brain,  the  sympathetic  nervous  system,  and  the  or- 
gans of  digestion.  The  influence  of  the  mind  over 
the  body  is  simply  tremendous,  and  both  the  patient 
and  physician  need  to  have  such  a  great  vital  force 
working  with  determinate  action  toward  health. 

The  second  step  in  the  treatment  of  these  cases  is 
no  less  important  than  the  first.  It  consists  in  thor- 
oughness, and  repeated  thoroughness,  in  examini  ig 
into  the  patient's  condition.  It  is  in  the  highest  de- 
gree essential  to  interrogate  over  and  over  again 
every  organ,  and  to  find  out  just  how  it  is  doing  its 
work.  To  obtain  the  desired  information  there  is 
no  better  method  than  carefully  inquiring  into  the 
patient's  habits  of  life,  the  duration  and  severity  of 


OF  THE  stomach    and    BOWEL8.  115 

his  subjective  symptoms,  tin;  significance  of  every 
physical  sign,  and  then  supplementing  .ill  this  with 
a  microscopical  and  chemical  study  of  the  blood,  the 
urine,  and  the  f aecal  discharges.  Careful,  scientific 
study  of  the  products  of  the  system,  made  daily,  is 
eminently  important  and  useful.  The  reason  lies  in 
the  fact  that,  if  the  machinery  of  the  system  is  out 
of  order,  its  products  will  be  faulty  ;  and  hence,  by 
studying  abnormal  products,  one  is  enabled  to  read, 
as  it  were,  the  condition  of  the  organs  that  made 
them  so.  If  a  study  of  the  urine  reveals  the  state 
of  the  kidneys,  is  it  not  just  as  reasonable  to  believe 
that  a  microscopic  study  of  the  blood  and  faeces  will 
disclose  the  state  of  the  stomach,  bowels,  and  blood- 
making  organs  ?  It  would  seem  to  need  no  argu- 
ment, then,  to  prove  that  a  daily  thorough  investi- 
gation of  the  excretions  and  products  of  the  system 
is  in  the  highest  degree  useful.  It  is  the  only 
means  of  accurately  determining  to  what  extent 
patients  are  digesting  their  foods,  to  what  degree 
the  liver  and  kidneys  are  doing  their  work,  and  just 
what  quality  of  blood  is  being  made. 

As  a  third  preliminary  consideration  it  is  highly 
necessary  to  place  every  patient  under  the  most 
favoring  hygienic  conditions.  In  those  cases  where 
the  affection  is  slight  or  limited  it  may  not  be 
necessary  to  impose  more  than  a  few  reasonable 
restrictions  upon  diet,  habits  of  life,  and  hours  of 
work  and  rest.  On  the  contrary,  where  there  is 
very  much  catarrhal  disease  of  either  the  stomach 
or  bowels,  it  is  usually  necessary  to  confine  the  pa- 
tient to  his  home  for  a  time,  and  carefully  regulate 
his  work,  recreation,  diet,  and  medical  treatment. 


11''.  FUNCTIONAL    AND   CATARRHAL    DISEA8E8 

[ndeed,  everything  pertaining  to  habits  of  business 
and  lit«-  should  be  so  regulated  as  to  save  nerve 

power,  and  the  severer  the  disease  t lie  greater  1 1 1» • 
necessity  of  this.  To  insure  this  result  in  had  cases 
the  patient  should  rest  half  an  hour  before  meals 
and  an  hour  and  a  half  after  meals.  In  other  and 
still  severer  cases  it  is  better  to  insist  on  the  pa 
tient's  resting,  sleeping,  if  possible,  from  one  to  two 
hours  every  forenoon,  or  else  on  his  not  getting  up 
until  an  hour  and  a  half  after  breakfast,  and  re- 
tiring immediately  after  lunch  and  remaining  in 
bed  until  the  next  morning.  The  great  object  and 
end  is  to  so  regulate  the  life  of  the  patient  as  to 
avoid  "overwork  and  underrest,"  economize  nerve 
force,  and  acquire  a  quiet,  calm,  tranquil  state  of 
body  and  mind. 

Having  thus  first  gained  the  confidence  and  good- 
will of  the  patient  and  directed  him  in  regard  to  In- 
habits of  life,  his  diet  and  rest,  the  next  thing  is  to 
endeavor  to  remove  fro  m  his  stomach  and  intestines, 
and  also  from  the  kidneys  and  liver,  all  morbid 
material.  As  you  are  well  aware,  the  lining  of  the 
stomach  and  bowels  in  the  diseases  under  consider- 
ation becomes  coated,  as  it  were,  with  the  morbid 
products  of  supersecretion  and  fermentation.  The 
secretions,  being  in  excess  for  a  long  time,  become 
thick,  tough,  and  stringy.  They  are  highly  acid  and 
laden  with  the  germs  of  fermentation.  Moreover, 
as  a  rule,  the  liver  and  kidneys  are  in  an  abnormal 
state  and  burdened  with  an  immense  amount  of 
morbid  material.  All  these  vitiated  and  unhealthy 
accumulations  need  to  be  eliminated  from  the  sys- 
tem.    In  other  words,  the  surfaces  of  the  alimentary 


OK   THE    STOMACH    AMi    BOWELS.  117 

tract  need  to  be  washed  off  and  the  organs  flushed 
out  in  order  to  put  them  in  a  healthy  condition. 
Especially  is  it  necessary  to  remove  the  bile  from 
the  blood  and  stomach.  Every  one  knows  thatthe 
effect  of  a  large  amount  of  bile  in  the  stomach  of  a 
well  person  is  to  greatly  interfere  with  the  appetite 
and  with  the  stomach  digestion.  If  such  is  its  effed 
in  people  who  are  otherwise  well,  it  is  not  difficull 
to  imagine  what  its  presence  does  in  the  stomachs 
of  those  who  are  in  poor  health  and  suffering  from 
catarrhal  disease  of  the  stomach.  Hence  the  im- 
portance of  freeing  the  stomach  of  vitiated,  offen- 
sive mucus  and  bile  by  giving  to  it  a  rapid  downward 
action.  This  can  be  done  in  several  ways,  but  I 
know  df  none  so  simple,  so  grateful,  and  so  effective 
as  washing  it  out  by  drinking  hot  water.  Long  ex- 
perience has  now  shown  that-quantities  of  hot  water 
dissolve  and  liquefy  the  mucus  and  bile,  stimulate 
the  secretory  and  excretory  glands,  and  excite 
downward  peristalsis  of  the  bowels.  It  is  believed 
that  morbid  substances  are  rapidly  eliminated  from 
the  system  in  some  such  manner.  And  this  leads 
me  to  say  that  in  such  cases  hot  water  needs  to  be 
taken  systematically,  under  the  direction  of  a  physi- 
cian who  appreciates  its  utility  and  knows  what 
effect  is  to  be  achieved.  At  the  beginning  of  treat- 
ment it  is  a  good  rule  to  order  the  patient  to  take 
one  glassful  an  hour  or  an  hour  and  a  half  before 
each  meal  and  on  retiring,  increasing  or  decreasing 
the  quantity  according  to  the  rule  to  be  given  fur- 
ther along.  It  should  not  be  taken  too  hot,  but  about 
as  hot  as  after-dinner  coffee,  or  at  a  temperature  of 
from  110°  to  120°  F.     The  patient  should  be  charged 


IIS  FUNCTIONAL    IND    I    ITARRHAL    DISEASES 

to  take  it  very  slowly,  consuming  fifteen  or  twenty 
minutes  in  sipping  a  glassful,  in  order  to  avoid  scald- 
ing the  mucous  surface  of  the  throat  and  stomach. 
Water  taken  too  hoi  mayinjure  the  lining  of  the 
stomach,  produce  a  dry,  feverish  condition,  or  art 
too  powerfully  and  promptly  on  the  skin.  There 
are  other  precautions  to  observe,  which  T  will  nun 
tion.  It'  the  glassful  <>r  more  taken  at  bedtime 
causes  too  frequent  urination  during  t  be  night,  it  call 
be  dispensed  with;  ifthepatienl  has  a  weak  heart, 
large  quantities  of  hoi  water  should  be  taken  verj 
slowly;  if  the  patient  has  a  tendency  to  haemor- 
rhages, the  water  taken  should  not  be  much  more 
than  lukewarm  and  should  be  taken  very  slowly  ; 
and  if  the  patient  is  a  woman  subject  to  long-con- 
tinued or  excessive  menstruation,  she,  too,  should 
take  water  very  slowly  and  at  alow  temperature. 
These  precautions  need  to  he  observed  so  as  to  avoid 
ill  effects  and  dangers  that  might  otherwise  super- 
vene.  If  at  anytime  the  hot  water  is  disagreeable 
to  the  patient,  a  little  salt,  pepper,  lemon  juice, 
aromatic  spirits  of  ammonia,  or  any  innocent  flavor 
ing  extract  may  be  added  to  suit  the  taste.  If  hot 
water  seems  to  nauseate  the  patient,  its  use  should 
still  be  persisted  in,  since  this  is  a  positive  evidence 
that  the  stomach  is  in  a  foul  condition  and  needs 
cleansing  ;  and,  as  evidence  that  cleansing  does  take 
place,  it  can  be  said  that,  after  an  abundance  of  hot 
water  has  been  used  for  a  time  and  the  bowels  get 
to  acting  from  two  to  four  times  daily,  as  they  Ere 
quently  do,  the  discharges  are  often  either  black  and 
sticky,  or  granular  like  coffee-grounds,  or  else  they 
contain  masses  of  exfoliated,  gelatinous  mucus. 


<>l<'   THE   STOMACH    AND    BOWELS.  L19 

We  often  he  .r  it  said  that  the  free  and  prolonged 
use  of  hot  water  tends  to  injure  the  system.  Some 
say  that  it  is  weakening,  that  it  weakens  the  nerves 
of  the  stomach,  that  it  causes  anaemia  of  the  sto- 
mach, that  it  interferes  with  digestion,  that  it  tends 
to  produce  a  flushed  face  and  cerebral  hyperaemia, 
that  it  debilitates  the  alimentary  tract,  and  that  it 
causes  a  host  more  of  most  direful  evils.  As  a  rule, 
all  these  objections  are  theoretical  and  come  from 
those  who  never  used  it  intelligently  and  system- 
atically, and  hence  are  ignorant  of  the  facts.  In 
reply  to  such  objections,  all  I  can  take  time  to  say 
is  that  I  have  used  hot  water  daily  for  six  years 
without  the  slightest  perceptible  injury,  and  have 
seen  only  uniformly  good  results  in  persons  for 
whom  I  have  prescribed  its  daily  and  long-contin- 
ued use. 

As  all  are  aware  from  experience,  it  is  always  a 
difficult  problem  to  successfully  feed  patients  who 
are  suffering  from  diseases  of  the  stomach  and 
bowels.  There  has  ever  been  a  demand  for  some 
article  of  food  that  would  not  ferment,  that  would 
afford  a  maximum  amount  of  nourishment,  and 
that  would  be  promptly  and  easily  digested.  At 
last  such  a  food  has  been  found,  for  we  know  that 
an  animal  diet,  or,  to  speak  more  specifically,  good, 
well-prepared  muscle  pulp  of  beef,  can  be  relied 
upon  for  the  purpose  before  named.  Inasmuch, 
however,  as  beef  varies  greatly  in  its  quality,  it  is 
necessary  to  exercise  care  in  selecting  that  which  is 
best,  and  this  is  found  in  the  centre  of  the  round 
of  a  well-fatted,  corn-fed  animal  from  three  to  six 
years  old.     This  portion  is  freest  from  fat  and  is 


120         FUNCTIONAL    \M>   CATARRHAL    DISEASES 

fche  richest  in  those  nutritive  elements  required  by 
the  human  system.  It  should  be  given  to  the  pa- 
fcient  in  the  form  of  beef  pulp,  which  may  he  pre- 
pared bythe  process  of  Bcraping,  or  by  passing  ii 

through  a  "  chopper  "  made  for  the  purpose.  The 
object  of  such  preparation  is  to  remove  all  of  the 
fibre  and  leave  the  pulp  in  a  condition  to  be  both 
palatable  and  easily  digested.  When  the  fat  and 
fibre  are  entirely  removed,  the  pulp  can  be  made 
into  cakes  containing  the  number  of  ounces  the  pa 

i  ient  is  able  to  digest.     These  cakes  should  be  ii 

half  to  three-quarters  of  an  inch  in  thickness,  care 
being  taken  not  to  pack  them  too  firmly.  The 
cake  of  beef  pulp  is  then  to  be  broiled  over  a  slow 
fire,  preferably  charcoal,  until  it  is  so  cooked  that 
the  outside  is  of  about  the  color  of  ordinary  broiled 
steak  and  the  inside  of  a  pinkish  hue.  Great  care 
should  always  be  taken  not  to  overcook  the  beef 
cake  and  so  make  it  dry,  brown,  juiceless,  and  in- 
digestible. If  it  is  cooked  just  right,  patients  will 
not  tire  of  it,  it  is  more  easily  and  thoroughly  di- 
gested, and  all  dangers  from  tapeworm  are  avoided. 
In  rare  instances  beef  prepared  thus  is  not  palatable 
at  first,  and  when  such  is  the  case  it  can  be  broiled 
between  two  pieces  of  dried  or  chipped  beef,  or  a 
lew  oysters  may  be  broiled  with  it  so  as  to  imparl 
their  flavor,  or  a  few  spoonfuls  of  beef  blood  or  ex- 
pressed beef  juice  freshly  extracted  from  the  beef 
may  be  added.  The  effort  should  be  to  employ 
simple  means  to  make  the  beef  palatable  to  the 
peculiar  tastes  and  fancies  of  the  patient.  The 
beef  pulp  thus  prepared  should  he  given  in  small 
quantities  at  first,  not  over  four  or  six  ounces  in  a 


OF  THE   STOMACH    AND    BOWELS.  I  i  I 

day,  until  its  effects  have  been  carefully  noted. 
Later  on,  as  the  stomach  and  bowels  become 
cleansed  and  more  tolerant,  the  quantity  may  he 
increased  to  eight,  ten,  twelve,  fourteen,  or  sixteen 
ounces  at  a  meal.  If  patients  tire  of  beef  prepa  red 
in  this  manner,  or  if  it  is  very  distasteful  to  them, 
it  is  better  not  to  insist  on  their  taking  it  for  a  time, 
but  to  let  them  have  instead  a  lean  chop,  or  a  small 
plain  steak,  or  a  little  game  of  some  kind,  like 
broiled  grouse  or  pheasant.  This  change,  however, 
should  be  as  temporary  as  possible,  and  an  early  re- 
turn made  to  beef  pulp,  for  from  this  comes  the 
maximum  nourishment  from  the  minimum  effort. 
If  the  functional  or  catarrhal  condition  is  not  too 
severe,  a  limited  quantity  of  starchy  food  may  be 
given,  such  as  a  small  piece  of  stale  roll,  or  a  piece 
of  dry  toast  about  one  or  two  inches  square.  It 
sometimes  happens  in  these  cases,  and  under  this 
restricted  animal  diet,  that  the  patient's  appetite 
will  seem  to  fail.  When  such  is  the  case  it  is  in- 
variably due  to  either  bile  in  the  stomach,  to  undi- 
gested food,  to  a  tired  and  depressed  state  of  the 
nervous  system,  or  else  to  a  combination  of  all  these 
conditions.  Under  such  circumstances  an  effort 
should  be  made  to  cleanse  the  stomach  as  rapidly 
as  possible  by  an  even  freer  use  of  hot  water,  limit- 
ing to  a  greater  degree  the  quantity  of  food  taken, 
and  insisting  on  more  physical  and  mental  rest. 
At  the  same  time  the  nerve  tone  should  be  improved 
as  rapidly  as  possible  by  tonics,  massage,  and  elec- 
tricity. But,  inasmuch  as  patients  differ  and  dis- 
eases vary  in  severity,  it  is  easy  to  understand  that 
.set  rules  in  regard  to  the  quantity  and  temperature 


L22  FUNCTIONAL    \\l>   CATARRHAL    DI8KA8E8 

of  water,  or  to  the  amount  of  animal  food  to  be 

given,  cannot  be  laid  down.  The  amount  of  ho1 
water  should  be  sufficient  to  maintain  the  specific 
gravity  of  the  urine  at  aboul  L.014,  and  the  quan- 
tity of  meat  should  be  as  much  as  can  be  digested. 

Whether  the   patient  is  drinking  enough  or  is  di 
gesting  his  food  properly  is  to  he  decided  by  the 
physician  and  never  by  the  caprice  of  the  sick  one. 

It  is  to  be  borne  in  mind  that  the  object  of  the  use 
of  hot  water  and  a  strictly  animal  diet  is  to  prevent 
excessive  fermentation,  which  is  the  underlying 
cause  of  the  diseased  condition,  and  therefore  it 
should  be  employed  systematically  and  persistently. 

It  is  alleged  by  some,  who  are  ignorant  of  facts, 
that  this  single  article  of*  diet  will  bring  on  dyspep 
sia,  Blight's  disease,  and  other  serious  troubles,  and 
that  it  tends  to  establish  a  sort  of  meat  habit,  so 
that  the  organs  of  digestion  will  not  tolerate  other 
kinds  of  food.  I  will  not  take  time  to  discuss  asser- 
tions and  theories,  but  simply  Bay  tli.it.  in  the  treat- 
ment of  hundreds  of  cases  according  to  the  methods 
here  given,  I  have  never  seen  any  evil  results.  On 
the  contrary,  patients  are  gradually  brought  around 
to  a  mixed  diet  as  soon  as  safe  for  them  ;  the  great 
majority  get  well,  so  that  they  can  eat  a  reasonable 
.iin«  unit  of  any  kind  of  food,  and  in  old  chronic  cases 
of  twenty  or  thirty  years'  standing  they  are  made 
comfortable  and  able  to  eat  all  that  is  necessary  1 « i 
supply  the  requirements  of  their  system. 

Having  thus  far  dwelt  on  the  general  principles 
of  treatment,  T  will  now  speak  a  little  more  specifi- 
cally of  the  treatment  of  functional  diseases  of  the 
stomach.     In  cases  of  this  nature  the  patient  should 


OF  THE   stomach    AND    BOWELS.  1^5 

beheld  very  closely  to  some  form  of  animal  food 

such  as  the  muscle  pulp  of  beef,  beefsteak,  lean 
mutton,  white  meats  of  fisb  and  poultry,  the  pulp 
of  oysters,  well-fried  bacon,  and  soft-boiled  or 
poached  eggs.  The  prepared,  muscle  pulp  of  beef 
may  be  used,  but  more  to  furnish  variety  than  be- 
cause really  essential.  But,  as  a  rule,  these  cases 
will  do  better  if  the  physician  advises  an  almost 
constant  use  of  either  broiled  or  roast  beef  or  mut- 
ton, eaten  slowly  and  thoroughly  masticated  before 
being  swallowed.  It  is  also  well  to  allow  a  very 
small  quantity  of  starchy  food,  in  the  proportion  of 
three  or  four  parts  of  animal  to  one  of  starchy  food 
by  bulk.  It  is  safest  to  advise  a  very  small  piece  of 
dry  toast — so  dry  that  it  will  snap — or  a  piece  of 
stale  roll,  or  a  small  piece  of  stale  bread,  or  a  table- 
spoonful  of  well-cooked  rice  or  cracked  wheat 
dressed  with  butter,  salt,  and  pepper.  In  the  mat- 
ter of  vegetables  it  is  well  to  advise  a  few  tender 
sprigs  of  celery,  a  little  watercress,  or  a  little  horse- 
radish, prepared  with  lemon  juice  instead  of  vinegar. 
Moreover,  the  patient  should  be  directed  not  to 
swallow  coarse  particles  of  any  of  the  substances 
named,  and  to  eat  a  moderate  quantity  and  very 
slowly.  The  drinks  to  be  allowed  at  meal  times 
are  a  single  after-dinner  cup  of  black  tea  or  black 
coffee,  sweetened  with  saccharin  if  desired.  If 
these  are  not  well  borne  a  cup  of  hot  water,  flavored 
or  not  with  lemon  juice,  may  be  taken.  If  the 
functional  cases  are  at  all  recent  and  these  precau- 
tions are  observed,  it  will  require  but  a  few  days  to 
show  a  marked  difference  in  the  fermentation  and 
in  the  comfort  of  the  patient.     As  soon  as  the  un- 


.' 1        FUNCTIONAL   AND   CATARRHAL    DISEASES 

comfortable  feelings  have  disappeared,  the  products 
of  fermentatioD  eliminated  from  the  blood,  1 1 1  *  * 
symptoms  and  physical  signs  of  fermentation  gone, 
and  as  soon  as  the  urine  shows  normal  characteris 
tics,  being  absolutely  free  from  biliary  coloring  mat- 
ter, the  patienl  may  be  given  a  larger  proportion  of 

Starchy  food — say,  one  of  staivby  to  two  of  animal 
food.  In  functional  cases  of  stomach  and  bowel 
disease  patients  are  to  be  kepi  on  this  routine  as  to 
food  and  drink  for  a  few  weeks  or  months  after 
the  evidences  of  excessive  fermentation  have  ceased. 
At  the  end  of  this  time  the  patient  may  be  led  up, 
little  by  little,  to  other  food,  such  as  fresh  garden 
peas,  string  beans,  half  of  a  baked  potato,  and  a 
few  peaches,  prunes,  or  grapes.  These  should,  be 
given  in  small  quantities  at  first,  and  if  they  cause 
any  trouble  they  should  be  discontinued  and  re 
course  had  to  a  rigid  animal  diet  until  the  digest  ion 
has  returned  to  a  normal  state.  And  here  let  me 
say  that  it  is  surprising  how  little  gas  is  contained 
in  the  intestines  of  people  whose  digestion  is  ab- 
solutely healthy.  It  is  equally  surprising  to  note 
the  serious  disturbance  of  the  mucous  membrane 
after  a  few  weeks  or  months  of  excessive  fermenta- 
tion. On  the  one  hand  I  have  seen  cases  that  have 
given  evidence  that  fermentation  had  existed  in  ex- 
cess for  twenty  or  thirty  years  wit  hout  perceptibly 
affecting  the  general  health.  On  the  contrary,  I 
have  seen  many  cases  where  the  most  serious  struc- 
tural changes  had  resulted  after  only  a  few  weeks 
of  indigestion  and  fermentation,  either  in  the  sto- 
mach or  bowels,  or  else  in  both.  It  can  only  be  said 
in  explanation  of  this  that  one  is  endowed   with 


OP   THE   STOMACH    AND    BOWELS.  L25 

great  resisting  power,  while  the  other  is  not  so 
blessed.  In  other  words,  these  conditions  work  hut 
little  injury  in  robust  persons,  while  in  others  of 
less  resistance  and  stamina  they  may  cause  decided 
damage  and  great  suffering.  Therefore  I  do  not  put 
very  great  stress  upon  fermentation  and  gas  when 
they  occur  in  people  of  good  health  ;  but  they  do 
have  a  very  decided  meaning  when  the  health  be- 
gins to  fail  and  there  are  indications  of  serious  struc- 
tural change  in  the  mucous  surfaces  of  the  stomach 
or  bowels. 

In  the  more  strictly  catarrhal  states  of  the  sto- 
mach or  bowels,  or  of  both,  their  lining  becomes 
coated  with  an  excess  of  sour,  offensive,  adherent 
mucus..  This  material  is  in  a  large  degree  a  fer- 
ment, and,  as  a  consequence,  sweet  and  starchy 
foods  are  soon  transformed  into  a  sour,  yeasty,  irri- 
tating, and  injurious  liquid.  If  this  state  of  things 
is  long  continued  it  almost  inevitably  causes  either 
vomiting  of  highly  acid  irritating  liquids,  or  else 
frequent  discharges  from  the  bowels  of  gaseous  jDro- 
ducts,  undigested  food,  and  thick,  stringy,  gelatin- 
ous mucus.  The  mucus  thus  cast  off  may  be  like 
the  white  of  an  egg,  only  more  yellow  ;  or  a  thin, 
black,  gelatinous  substance  ;  or  a  thin,  stringy  ma- 
terial resembling  wet  tissue  paper  ;  or,  lastly,  a  dis- 
tinct membranous  exfoliation.  It  is  in  cases  of  this 
kind  that  an  abundance  of  hot  water,  long  con- 
tinued, is  of  the  highest  utility  for  washing  out  the 
products  of  fermentation  and  keeping  the  surfaces 
in  a  fit  condition  for  digestion  and  absorption.  This 
practice  must  be  continued  and  persevered  in  for 
month ;  and  years  before  the  alimentary  tract  be- 


L26  i'i   NOTIONAL     IND    CATARRHAL    DISEASES 

comes  thoroughly  cleansed  and  restored  to  the 
power  and  function  of  normal  digestion.  In  catar- 
rhal cases  of  the  stomach  the  besi  food  is  the  muscle 
pulp  <>f  beef,  prepared  in  accordance  with  the  meth- 
ods described,  and  given  as  the  patienl  is  able  i«»  di- 
gest.  It  is  well  i<»  hold  patients  on  this  diel  from 
mu-  to  three  months,  because  it  is  the  only  one  thai 
<-;ui  lie  anywhere  near  perfectly  digested.  Later  on 
<  it  In 'i'  foods  can  lie  resumed,  but  with  great  caution. 
Among  the  first  foods  to  be  given  should  be  fresh 
garden  peas,  string  brans,  fresh  warm  milk  from 
the  cow,  a  little  tomato,  or  a  few  prunes,  peaches, 
or  grapes.  The  foods  allowed  at  first  should  be 
guarded!)  chosen  and  taken  in  a  cautious  manner. 
Little  by  little  the  diet  should  he  extended  until 
ordinary  diet  can  he  taken  with  comfort.  If  at 
anytime  the  patient  shows  signs  of  not  digesting 
his  foods,  he  should  be  brought  hack  at  once  to 
the  rigid  animal  diet  and  held  there  until  the  or- 
gans again  do  perfect  work.  If  the  patient  is  thus 
promptly  and  strictly  returned  to  a  restricted  animal 
diet,  he  will  be  all  right  in  a  few  days.  On  the  con- 
trary,  if  he  is  not  so  treated  the  former  manifesta- 
tions of  disease  will  occur.  It  is  impossible  fora  per- 
son ever  to  get  so  well  hut  that,  if  he  becomes  sick 
again,  it  will  be  the  weak  organs  that  are  assailed. 
Like  causes  will  certainly  produce  like  effects.  It 
is  to  be  borne  in  mind  that  the  mucous  membrane, 
while  it  may  be  sound,  is  still  delicate  and  sensitive, 
and  must  be  restored  and  strengthened  up  to  it  - 
natural  state.  And  if  you  consider  particularly  the 
changes  that  have  taken  place  in  advanced  cases. 
not  only  in  the  mucous  membrane  but  in  the  con- 


OF   THE   STOMACH    AND    BOWELS.  I'.', 

nective  tissue,  glands,  and  sympathetic  nerves,  it 
stands  to  reason  that  a  good  condition  must  lx:  kept 
up  long  after  the  evidences  of  tin:  disease  have  dis- 
appeared. And  I  might  add  in  this  connection  that, 
in  my  experience,  it  takes  from  one  to  three  years 
to  bring  about  such  changes  and  to  cure  a  catarrh 
of  the  stomach  and  bowels. 

In  catarrhal  disease  of  the  bowels  much  the  same 
line  of  treatment  is  to  be  followed.  The  use  of  hot 
water  and  the  rigid  animal  diet  must  be  persevered 
in  until  all  traces  of  the  disease  have  disappeared 
from  the  blood,  the  urine,  and  the  faeces.  After 
this  system  of  alimentation  has  been  persevered  in 
thus  long,  there  may  be  a  very  gradual  return  to  the 
vegetable  and  starchy  regimen  already  defined.  At 
times  there  may  be  slight  relapses,  but  these  will 
be  readily  corrected  by  a  return  to  a  rigid  use  of  the 
hot  water  and  animal  diet  for  a  few  days.  But, 
despite  drawbacks,  there  will  be  a  prompt  resto- 
ration of  comfort  and  a  gradual  progress  toward 
health  until  recovery  is  complete. 

The  extent  to  which  I  have  gone  into  the  general 
principles  of  treatment  and  diet  may  lead  to  the  be- 
lief that  I  am  indifferent  to  the  place  and  power  of 
medicines  in  dealing  with  the  functional  and  ca- 
tarrhal diseases  of  the  stomach  and  bowels.  Such, 
however,  is  not  the  case,  for  there  are  medicines  of 
very  great  utility  and  upon  which  I  have  come  to 
rely  with  confidence.  In  my  judgment  there  are 
four  leading  indications  for  the  use  of  medicines  in 
these  cases.  There  is  a  need  for  those  that  supple- 
ment the  gastric  juice,  that  stimulate  the  appetite, 
that  invigorate  the  nervous  system,  that  excite  or 


i'.'s  FUNCTIONAL    AND   CATARRHAL    DISEASES 

retard  the  Becretioiis,  and  thai  bear  upon  oomplica- 
tdons  which  may  arise. 

l.  Among  those  of  the  first  class  is  to  be  named 
pepsin,  which  is  especially  useful  in  aiding  the  di- 
gestioa  of  animal  food.  Tothisuseful  agent  may 
he  added  either  bismuth,  ginger,  or  ipecac,  as 
needed. 

•_'.  Of  the  medicines  calculated  to  stimulate  the 
appetite  I  have  found  benefit  to  result  from  the 
preparations  of  cinchona,  gentian,  fluid  extract  of 
stillingia,  and  FothergilTs  antidyspeptic  pills. 

3.  Ju  cases  that  need  ;i  decided  nerve  tonic  to  in- 
vigorate a  feeble  nervous  system,  and  especially  the 
nerves  supplying  the  organs  of  digestion,  there  is 
nothing  more  advantageous  than  the  preparations 
of  strychnine  and  damiana. 

4.  For  remedies  to  regulate  the  secretions  I  have 
obtained  good  results  from  the  guarded  use  of 
Carlsbad  salts,  compound  licorice  powder,  fluid  ex- 
t  pact  of  cascara,  mild  laxative  pills,  and  hydrastin. 
On  thecontrary,  when  secretions  become  too  free 
I  often  prescribi  mild  tonic  astringents,  like  the 
fluid  extract  of  blackberry  root,  fluid  extract  of 
hamamelis,  bismuth,  or  chalk  mixture.  In  catarrh 
of  the  stomach,  duodenum,  or  bowels  a  combina- 
tion of  hydrastin  and  bismuth  has  rendered  most 
excellent  service.  Hydrastin  and  bismuth  seem  to 
exert  a  peculiar  and  salutary  effect  upon  mucous 
surfaces.  In  those  cases  where  there  is  a  marked 
tendency  to  acidity  and  fermentation,  salicin  alone. 
or  with  bicarbonate  of  sodium,  or  charcoal  and 
magnesia,  have  given  good  and  prompt  results. 
Salicin  usuallv  affords  excellent  results,  because  it 


OF  THE   STOMACH    AND    BOWELS.  129 

does  not  disturb  the  stomach,  is  tonic,  in  its  action, 
and  is  one  of  the  best  agents  we  have  to  counter 
act  acidity  and  the  evils  of  fermentation.  There 
are,  of  course,  many  other  remedies  to  be  used  in 
the  treatment  of  the  diseases  under  consideration, 
but  these  are  the  principal  ones  which,  if  properly 
prescribed,  are  of  great  service. 

In  conclusion,  there  are  two  features  in  the  clini- 
cal history  of  cases  treated  after  the  manner  here 
outlined  that  are  worthy  of  special  note.  In  the 
first  place,  there  is  a  natural  tendency  for  the  pa- 
tient to  gradually  get  weaker  and  thinner.  The 
deprivation  of  starch,  sugar,  and  fat  cuts  off,  so  to 
speak,  the  "kindling  wood"  of  the  system  that  af- 
fords immediate  strength  and  heat.  Not  only  that, 
but  excessive  fermentation,  especially  alcoholic,  is 
to  some  extent  a  stimulant,  and  it  is  the  loss  of  its 
chrome  effects  that  is  felt  by  the  system.  No  inju- 
rious consequences  follow  this  weakness,  however, 
if  the  patient  believes  what  has  been  told  him  and 
does  as  advised.  After  a  time  the  blood  becomes 
richer,  the  nervous  system  stronger,  and  renewed 
strength  takes  the  place  of  former  debility.  If  nec- 
essary, as  a  matter  of  bridging  over  temporary 
weakness,  the  patient  can  be  given  from  a  tea- 
spoonful  to  a  tablespoonful  of  old  whiskey  or 
brandy,  in  water,  from  one  to  two  hours  after 
meals. 

And,  secondly,  in  catarrhal  cases  of  the  bowels 
where  the  movements  occur  several  times  daily,  it 
is  sometimes  necessary  to  bring  them  under  con- 
trol with  simple  remedies,  like  external  heat,  rest 
in  bed,  and  the  internal  use  of  mild  doses  of  bis- 
9 


L30  II   Si   PIONAL    VN1>   CATARRHAL    DISEASES 

iniiili.  chalk  mixture,  or  fluid  extracl  of  ginger. 
These  rather  frequenl  movements,  while  they  some- 
times weaken,  are,  after  all,  salutary*.  They  are, 
as  it  were,  Nature's  "house  cleaning,"  removing 
the  products  of  fermentation,  exfoliations  of  mucus, 
and  other  i  noil  >id  material.  Before  or  during  these 
frequent  movements  or  clearings  the  patienl  may 
experience  Local  or  general  muscular  or  neuralgic 
pains,  bul  all  of  these  temporary  disi  iirbances  soon 
pass  away. 

Such,  then,  art>  the  methods  which,  in  my  judg- 
ment, are  the  best  of  all  for  removing  the  causes 
of  functional  and  catarrhal  diseases  of  the  stomach 
and  bowels,  restoring  the  quantity  and  quality  of 
the  blood,  augmenting  the  force  of  the  nervous 
system,  and  putting  the  general  health  on  a  solid 
basis. 

As  you  have  already  heard,  they  consist — 

1.  In  securing  a  willing,  obedient,  hopeful,  and 
confident  mental  condition. 

2.  In  making  a  careful  diagnosis,  based  on  the 
usual  methods,  and,  in  addition,  a  frequent  micro 
scopical  and  chemical  study  of  the  products  of  the 
system,  as  the  blood,  the  urine,  and  the  faecal  dis- 
charges. 

:'>.  In  placing  the  patient,  under  the  most  favoring 
hygienic  conditions. 

4.  In  an  intelligent  and  systematic  use  of  hot 
water  for  the  purpose  of  cleansing  the  surfaces  of 
the  stomach  and  bowels,  stimulating  the  secretory 
and  excretory  functions  of  the  liver,  kidneys,  and 
other  glands,  and  supplying  the  system  with  the 
requisite  amount  of  liquid. 


OF   THIO   STOMACH    AND    BOWELS.  L3J 

5.  In  using  an  article  of  diel   that  undergoes  bul 

slight  if  any  fermentation,  that  can  be  easily  di- 
gested, absorbed,  and  assimilated,  and  that  will 
make,  in  time,  the  maximum  amount  of  blood  and 
nerve  force.  The  great  object  is  not  to  arbitrarily 
put  the  patient  on  a  particular  article  of  diet,  bin 
rather  on  one  that  will  meet  the  above-named  re 
quirements  and  tide  him  over  until  well  enough  to 
resume  the  use  of  various  articles.  For  this  pur- 
pose I  have  not  found  any  food  comparable  to  the 
muscle  pulp  of  beef,  prepared  and  used  as  before  de- 
scribed. To  afford  the  greatest  service  it  must  be 
carefully  prepared,  properly  eaten,  and  thoroughly 
digested.  To  know  whether  it  is  well  digested,  re- 
liance must  be  placed  on  the  usual  signs  and  symp- 
toms, and  on  a  frequent  microscopical  and  chemi- 
cal study  of  the  blood,  the  urine,  and  the  faeces. 
The  latter  method  affords  the  most  accurate  means 
of  determining  what  manner  of  work  is  being  done 
in  the  laboratory  of  the  system. 

6.  In  the  use  of  medicines  in  so  far  as  they  im- 
prove the  appetite,  excite  or  retard  secretions,  re- 
store the  blood  and  nervous  system,  and  meet  vary- 
ing conditions  and  complications,  if  any  develop. 


II. 

On  the   Nature  and   Preventive  Treatment  of 
Seasickness. 

Nowadays  inventive  genius  and  the  progress  of 
science  have  made  travel  by  sea  rapid  and  safe. 
The  greal  steamers  pass  quickly  and  triumphantly 
againsl  wind  and  wave  from  poinl  In  |».«in1  and 
from  shore  to  shore.  Tin1  world  IS  made  smaller, 
nation  is  drawn  closer  1"  nation.  Seasickness  is 
the  chief  barrier  thai  remains;  it  is  the  almost  cer 
tain  affliction  of  those  who  use  this  mode  of  travel, 
be  it  for  health,  pleasure,  education,  or  the  pur- 
poses  of  hade.  This  peculiar  form  of  vertigo  it  is 
that  Neptune  imposes  as  a  tax  on  all  of  his  subjects, 
excepl  a  favored  few.  It  is  estimated  that  only 
about  three  per  cenl  of  all  sea-goers  are  exempt. 

Mechanical  science  has  very  materially  shortened 
the  duration  of  the  disease  by  increasing  the  rapid 
ity  and  comforts  of  travel.      The  layman  has  pretty 
thoroughly  discussed  the  subject,  and  seems  never 
to  tire  when  considering  its  humorous  side.     The 
medical  profession  has  done  very  little,  ami  written 
and    thoughl    less.       It    is  with    the   desire   to    excite 
serious  study  of   this   neglected  disease    that    this 
article  is  written.     X<>  effort    is  made  to  discover 
'•some  new  thing";  no  claim  will  be  made  for  ori 
ginality.     The  united  thought  of  the  profession  ma\ 
he  able  to  lift  the  cloud   1  hat  obscures  the  nature  of 


NATURE   AND  TREATMENT   OP  SEASICKNESS.       L33 

the  trouble,  and  devise  some  means  for  its  preven- 
tion or  alleviation. 
On  account  of  the  nature  and  limited  adaptability 

of  our  organism,  which  is  fitted,  by  creation  and 
habit,  to  life  on  the  stable  and  solid  lai  id ;  on  account 
of  the  great  change  in  the  environment  when  on 
the  restless  sea,  it  is  folly  to  hope  that  the  evil  can 
be  wholly  overcome.  So  long  as  the  rolling  and 
pitching  ship  is  at  the  mercy  of  every  wave,  and, 
impressing  its  restlessness  on  every  object  that  can 
be  felt  and  seen,  takes  from  us  the  guides  and  gov- 
ernors of  co-ordination  and  of  equilibration  ;  so  long 
as  these  disordering  and  uncorrected  sensory  im- 
pressions possess  correlatives  in  consciousness,  the 
vertigo  of  mariners  will  be  produced.  For  seasick- 
ness is  essentially  and  primarily  a  disordered  sense 
of  equilibrium  and  of  space,  a  sensory  form  of  ver- 
tigo. 

The  symptoms  and  their  order  and  manner  of  de- 
velopment confirm  this  view.  The  first  and  essen- 
tial sign  of  every  case  of  seasickness  is  a  feeling  of 
dizziness  or  lightness  of  the  head,  or  vertigo.  It  is 
the  most  invariable,  and  the  most  persistent,  and 
sometimes  the  only  symptom.  It  is  alone  present 
in  the  prelude;  though  overshadowed,  is  never  ab- 
sent from  the  scene  ;  and  is  the  last  to  leave  the 
stage  when  the  curtain  falls.  It  is  commonly  asso- 
ciated with  headache,  an  indefinable  nervousness, 
sensitiveness  to  light,  a  contracted  pupil,  and  a 
keen  sense  of  smell.  The  temper  is  extremely  irri- 
table, the  face  is  flushed  or  pale,  or  rapidly  changes 
from  the  one  to  the  other  state — the  vaso-motors 
and  inhibition  are  struggling  for  the  mastery.     The 


<>N   Tin:   \  \  n  i;r.    wi» 

condii  ion  is  one  of  hyperemia  and  instability  of  the 
sensory  and  sympathetic  nerve  centres.    These  epi 
phenomena  may  be  absent   and  the   voyage  com 
pleted  with  only  varying  degrees  of  vertigo.     Bu1 
more  "Hen  the  Bimple  vertigo  is  followed  by  ner 
vous  exhaustion  and  mental  depression,  muscular 
inco-ordination  and  relaxatioD,  a   nv.-ik  heart,  low 
arterial  t<-n<i« »n.  salivation,  nausea,  and  vomiting, 
Tli.'  irritability  of  weakness  supplants  the  sensory 
excitement,  and  t  lie  vertigo  is  increased  by  the  cere- 
bral anaemia. 

Tims  we  have  three  pretty  well  defined  forms  or 
degrees  <>f  seasickness  -sensory  vertigo,  sensory 
vertigo  with  cerebro-spinal  irritability,  and  vertigo 
with  prosl  ration. 

The  form  and  degree  and  duration  of  the  attack 
depend  on  Hie  nature  andintensity  <>t'  tin'  move 
ments  <>fih<'  ship,  on  the  susceptibility  and  adapt- 
ability of  the  individual,  and  the  incidence  of  fche 
disturbance.  When  the  cerebro-spinaJ  system  i- 
most  involved,  vertigo,  headache,  and  nervousness 
are  marked  ;  when  the  sympathetic  is  weakest,  the 
nausea,  vomiting,  and  prostration  are  mosl  ])i<>ini- 
ni'iit . 

The  nervous  irritability  may  be  explained  as  the 
result  <>f  the  cerebral  excitement  ami  t  he  uncommon 
and  oumerous  sensory  impressions.  The  cerebro- 
spinal hyperemia  is  due  partly  to  the  increase  of 
functional  activity,  and  partly  to  the  tonic  contrac- 
tion of  all  the  muscles  driving  the  blood  out  of  the 
musculo  -venous  reservoir.  Every  peripheral  exci 
tation  determines  neural  discharges  and  causes  an 
augmentation  of  potential  energy.      It  is  also  well 


PREVENTIVE   TREATMENT   OF   SEASICKNESS.         I  ■'>■'> 

known  that  the  pupil  contracts  under  the  influence 
of  exciting  sensations,  as  docs  also  the  whole  reflex 
muscular  system. 

The  vomiting,  in  the  popular  mind,  constitutes 
the  essential  part  of  the  malady.  Many  physiriaie. 
it  must  be  admitted,  adopt  this  idea  and  embody  it 
in  their  treatment.  Now,  we  would  state  with  em- 
phasis that  acute  dyspeptic  attacks  must  not  be 
confounded  with  seasickness.  Acute  dyspepsia  is  a 
powerful  predisposing  cause  of  the  disease,  bul  has 
no  relation  whatever  to  the  movements  of  the  ship. 
The  cause  must  be  sought  in  overeating,  irregular 
habits,  loss  of  sleep,  overwork,  worry,  anxiety, 
grief,  the  abuse  of  drugs — in  some  gross  violation 
of  the  hygiene  of  digestion.  The  disturbance  of  the 
stomach  is  primary  and  would  have  occurred  under 
similar  circumstances  on  land.  The  vomiting  of 
seasickness  seems  to  be  the  effect  of  the  cerebral 
anaemia  produced  by  the  weak  heart,  vaso-motor 
disturbance,  and  muscular  relaxation — all  due  to 
paresis  of  the  sympathetic  from  fatigue  of  the  nerve 
centres  by  sensory  overexcitation,  or  from  emotive 
shock,  or  from  excessive  inhibition  through  a  sense 
of  defective  motor  innervation  and  of  failure  to 
preserve  the  equilibrium  of  the  body. 

From  this  analysis  it  will  appear  that  the  symp- 
toms referable  to  the  nervous  system  are  primary 
and  controlling,  and  that  the  essential  sign  of  sea- 
sickness is  vertigo.  This,  then,  limits  the  explana- 
tion to  the  production  of  the  vertigo  by  the  ever- 
varying  and  complicated  movements  of  the  ship, 
for  all  observers  agree  that  this  is  the  remote  cause. 
How  is  the  vertigo  produced  ? 


on'   THE    NATURE    ANl> 

The  process  is  nol  a  simple  one.  Many  theories 
fall  short  of  the  mark  because  they  do  nol  include 
enough  ;  because  it  is  incorrectly  assumed  that  onlj 
one  line  connects  the  cause  with  the  effect.     It  is 

11  iy  purpose  to  show  that  the  motion  of  the  ship  is 
connected  with  the  vertigo  by  many  routes  that 
the  mechanical  cause  splits  up  and  reunites  id  the 
biological  effect.  On  the  one  hand  we  have  the 
movements  of  the  ship,  and  on  the  other  are  the 
disturbed  sense  of  equilibrium  and  of  spare  mani 
test  in  consciousness  as  vertigo.  How.  then,  dothe 
movements  of  the  ship  disturb  these  two  senses  in 
this  peculiar  manner  '. 

It  is  foreign  to  our  purpose  to  discuss  the  nature 
of  the  sense  of  equilibrium,  whether  it  be  the  corre- 
late in  consciousness  of  afferent  sensory  impressions 
or  a  central  sense  of  motor  innervation.  Nor  would 
.- 1 uy thing  be  gained  by  disproving  the  existence  of 
so-called  spinal  and  muscular  perception.  It  is  the 
realil  y  and  composition,  and  not  the  location,  of  the 
sense  of  equilibrium  with  which  we  are  concerned. 
The  sense  of  equilibrium  is  a  compound  one  and  is 
correlated  in  consciousness  with  many  peripheral 
impressions— muscular,  tactile,  labyrinthine,  visual, 
and  from  pressure.  Through  the  muscular  we  are 
cognizant  of  the  state  and  position  of  a  part  as  re- 
lated to  the  rest  of  the  body.  By  the  other  sens.  .1  y 
impressions  we  are  informed  as  to  the  relation  of 
the  body  to  surrounding  objects  and  to  the  vertical 
position.  Now,  the  perfection  of  the  sense  of  equi 
librium  is  dependent  on  the  integrity  of  the  sensor} 
impressions  which  compose  it,  When  the  informa- 
t  ion  is  false  or  falsely  interpreted  the  motor  inner- 


PREVENTIVE    TREATMKN'f    OK    SEASICKNESS.       Hit 

vation  will  be  wrong  and  the  resull  bewildering. 
When  the  perception  of  id.il  ions  is  incomplete  and 
deceptive  and  uncorrected,  there  result  inco-ordina- 
tion  and  unsteadiness  and  \ rerl  igo. 

The  disordered  sense  of  equilibrium  is  suf'ficienl 
alone  to  produce  the  vertigo  of  mariners,  for  the 
blind  are  not  exempt.  Deafness  seems  to  confer  a 
certain  degree  of  immunity,  and  closing  the  eyes 
will  often  diminish  the  vertigo.  It  is  through  the 
sense  of  sight  and  the  perception  of  the  muscular 
changes  of  convergence  and  divergence  and  accom- 
modation that  the  sense  of  space  is  built  up.  In- 
sufficiency and  inco-ordination  of  the  ocular  mus- 
cles often  give  rise  to  vertigo.  It  is  through  the 
eye  also  that  we  are  chiefly  made  cognizant  of  our 
position  in  space.  Where  the  perceiving  subject  is 
in  motion  the  false  perception  of  relations  is  pro- 
jected outward  as  an  illusion  of  moving  objects. 
The  subjective  feeling  of  this  disorder  is  vertigo. 
The  dizziness  of  high  altitudes  and  openness  or  void 
arise  from  a  disordered  sense  of  space. 

Vertigo  may  be  divided  into  three  large  classes  : 
It  may  be  cardio-vascular,  as  the  vertigo  of  cerebral 
anaemia  or  of  arterial  sclerosis  ;  it  may  be  of  central 
origin,  as  the  vertigo  of  properly  located  brain  tu- 
mors ;  or  it  may  be  the  peripheral  or  sensory  form, 
of  which  the  vertigo  of  Meniere's  disease  and  sea- 
sickness may  be  taken  as  a  type.  We  have  already 
stated  that  the  vertigo  of  seasickness  with  pros- 
tration is  partly  due  to  cerebral  anaemia,  or.  in 
other  ^vords,  is  also  cardio-vascular.  But  the  es- 
sential and  primary  vertigo  is  of  a  purely  sensory 
origin. 


ON     I  Hi:    MATURE     \  N  D 


The  preservation  of  equilibrium  is  dependent  on  •. 
(1)  the  integrity  of  afferent  impressions;  (2)  on 
proper  motor  innervation  guided  by  pasl  experience, 
and  grouped  and  limited  so  as  to  produce  a  pur 
posive  movement  or  maintain  a  definite  relative 
position ;  (3)  on  proper  muscuL  r  response,  (4)  fche 
result  of  which  is  reflected  to  the  co  ordinating  and 
higher  centres,  and  there  is  appreciated  as  efficient 
ordefective.  Wnenonan  irregularly  moving  bod) 
none  of  these  conditions  can  be  realized,  and  on 
board  a  Bhip,  in  a  rough  sea,  fche  difficulty  may  be 
insurmountable.  The  sensori-motor  nerve  circuit 
carries  within  itself  fche  power  of  co-ordination  with- 
out the  connection  or  intervention  of  fche  higher 
centres,  though  the  higher  centres  may  regulate  or 
coi  it  rol.  Equilibration  is  commonly  an  unconscious 
process.  We  arc  not  conscious  of  nil  the  peripheral 
impressions  winch  are  co-ordinated  into  vertiginous 
movements;  we  merely  have  a  sense  of  the  defec- 
tive motor  innervation.  The  defect,  the  discord, 
the  false  association,  the  confusion  of  relations,  are 
('.■It  as  vertigo  if  they  rise  into  consciousness  or  me 
not  displaced  by  a  more  potent  feeling. 

With  these  explanations  turn  we  now  to  the  con- 
sideration of  the  manner  in  which  the  senses  df 
equilibrium  and  of  space  me  disturbed  by  the  move 
ments  of  the  ship  as  it  pilches  or  rolls  or  mixes  the 
two  motions.  The  body  is  constantly  thrown  out 
of  equilibrium,  and  the  position  of  the  surface  which 
supports  it  cannot  be  appreciated.  The  sensations 
of  contact  and  of  pressure  ever  vary  in  degree  and 
in  direction  now  slight  as  the  ship  sinks,  the  in- 
dividual  I'eeling  .-is  if  left  in  midair;  now  great  as 


I'UKVKNTIVK   TKKATMKNT   OF   SEA8ICKNE88.       L39 

the  ship  rises  and  presses  against  the  descending 
body.  The  same  uncommon  and  confusing  sensory 
impressions  arise  also  from  the  movable  visrcni  ;in<l 
internal  sensory  surfaces,  particularly  from  the 
semicircular  canals,  through  oscillations  of  theendo- 
lymph  or  hypersemia  of  the  auditory  centre — sensa- 
tions associated  in  experience  with  other  positions 
of  the  body  than  that  which  it  now  occupies.  No 
change  in  movement  can  be  anticipated  ;  no  posi- 
tion of  the  body  can  be  thoroughly  made  out.  The 
sense  of  sight  cannot  be  utilized  to  correct  and 
guide — an  ever-changing  point  of  view  amid  ever- 
changing  objects  ;  all  the  sensory  impressions  which 
make  up  the  life  of  relations  are  bewildering.  The 
fault  does  not  lie  in  perception,  nor  in  co-ordination, 
nor  in  the  periphery — the  sensory  mechanism  works 
perfectly.  It  is  because  the  sense  of  want  of  sup- 
port and  the  other  peripherally  excited  afferent  im- 
pressions are  disordering.  It  is  because  new  sensa- 
tions, from  an  environment  to  which  the  organism 
is  not  adapted,  obtain  a  false  association  in  con- 
sciousness. It  is  because  relations  cannot  be  made 
out  as  they  really  are  ;  because  the  erroneous  infer- 
ences as  to  the  relations  of  the  body  to  objects  seen 
and  felt  are  out  of  harmony  with  the  other  sensory 
impressions ;  because  the  results  of  the  efforts  to 
maintain  equilibrium  cannot  be  verified.  And  the 
central  confusion  and  discord  and  false  association 
are  projected  into  the  outer  world  as  illusions  of 
movement  and  of  space — a  simple  disorder  of  rela- 
tions— a  sensory  form  of  vertigo.  Such  seems  to  be 
the  explanation  of  the  vertigo  which  is  the  cardinal 
sign  or  synonym  of  seasickness. 


1  K)  I  ►»    lllK    NATURE    A.ND 

There  are  few  Bubjecta  at  once  bo  unsettled  and 

so  speculated  about  as  the  causation  of  seasickness 
It  is  not  contended  thai  the  view  here  set  forth  is 

complete  and  final  But  it  is  believed  to  contain 
the  germ  of  the  truth,  and  is  based  on  the  study  of 
the  symptoms  in  the  light  <>f  physiology  and  patho- 
logy.   It  best  explains  all  the  phenomena,  and  the 

Cause  acting  in  the  manner  indicated  will  produce 
the  vertigo  to  which,  and  to  the  condition  of  the 
cerebro-spinal  and  ganglionic  uerve  centres,  all  the 
symptoms  are  sequential. 

It  may  be  of  interest  to  mention  briefly  and  in 
the  order  of  their  publication  the  theories  which  at 
different  times  have  commanded  the  most  consid- 
eration and  credence  : 

1.  It  is  due  to  fear  (Plutarch),  proof  of  which  is 
that  infants  who  cannot  reason,  and  animals,  are 
exempt  (Gerepratte). 

This  theory  is  only  interesting  because  it  still  sur- 
vives in  the  pretty  widespread  relief  that  the  develop- 
ment of  seasickness  can  be  influenced  or  prevented 
by  the  exercise  of  the  will  and  a  mental  attitude  of 
indifference.  Nothing  can  be  more  ludicrous  than 
a  traveller  t  tying  to  ward  off  seasickness  by  force  of 
will,  unless  it  be  a  philosopher  striving  to  suppress 
a  toothache,  or  a  poet  to  charm  away  the  gout  by 
the  power  and  sweetness  of  his  song.  Strong  feel- 
ings and  powerful  emotions  can  temporarily  sup- 
plant in  consciousness  the  sensation  of  vertigo. 
Animals  are  not  exempt,  though  they  do  not  vomit. 
The  cause  alleged  is  inadequate,  and  the  evidence  is 
made  up  of  false  observation. 

2.  It  owes  its  existence  to  sympathy  between  the 


PREVENTIVE   TREATMENT   <>l''   SEASICKNESS.        Ill 

brain  and  peripheral  nerves  disturbed  by  the  move 

ments  of  the  ship  (175(5,  (iillchrist). 

In  the  early  dawn  of  physiology  this  is  ;i  very 
shrewd  guess. 

3.  It  is  due  to  cerebral   congestion   and   irritation 
arising  from  minute  concussions  of  the  brain  by  the 
fluids  of  the  body  during  the  descent  of  the  ship, 
analogous  to  the  rise  of  the  mercury  as  the  baro 
meter  is  dropped  (1810,  Wollaston) 

Minute  concussions  would  produce  headache  ana- 
logous to  that  from  riding  a  rough  horse,  but  not 
vertigo.  The  onset  should  always  be  gradual  and 
slow.  Slight  movements  should  have  no  effect.  A 
simple  change  in  the  character  or  cessation  of  the 
movements  should  never  remit  or  inaugurate  the 
trouble.  The  cause  is  inadequate,  cannot  be  shown 
to  be  operative,  and  the  blood  vessels  are  fortunately 
not  dead,,  rigid  tubes.  Infancy  with  its  soft  blood 
vessels,  and  old  age  with  its  hard  arteries,  are  alike 
almost  exempt. 

4c.  It  is  produced  by  the  influence  of  the  visceral 
movements  on  the  diaphragm  (1824,  Jobard  and 
Kerandreu). 

Again  the  influence  is  inadequate.  The  symp- 
toms are  not  reproduced  or  explained  in  the  order 
of  their  development.  And  fixation  of  the  viscera 
by  an  abdominal  band  exerts  only  a  slight  influ- 
ence by  diminishing  the  peripherally  excited  im- 
pressions. 

5.  The  movements  of  the  ship  in  an  arc-like  zig- 
zag line  arouse  a  centrifugal  force  which  so  influ- 
ences the  circulation  in  the  aorta  as  to  diminish  the 
amount  of  blood  going  to  the  brain.     The  anaemia 


1  12  I  >N   THE  N  ITU  RE    \  Vl» 

of  the  brain  results  in  cerebral  depression,  which 
through  ili«'  sympathetic  invokes  vomiting.     This 
author  considers  tli«'  vomiting  a  conservative  pro 
cess  induced  to  supplement  the  deficienl  quantity  of 
blood  senl  to  the  head  I  is»7.  Pellarin). 

This  is  an  exquisite  use  of  "occult  influences" 
and  the  reputed  "beneficent  purposes"of  Nature. 

6.  It  is  intoxication  by  a  marine  miasm  developed 
in  the  decaying  animal  and  vegetable  matter  of  the 
sea,  and  aroused  from  its  hiding  place  during  the 
agitation  of  the  water  by  the  ship  or  wind  or  wave 
( L850,  Semanas). 

If  this  theory  were  fresh  from  a  bacteriological 
laboratory  it  might  command  nowadays  a  great  deal 
of  consideration.  It  was  based  ona  false  analogy. 
I  '.in  tlie  large  doses  of  quinine  recommended  may  be 
of  benefit  by  producing  anasmia  of  the  semicircular 
canals  I  if  this  condition  be  true). 

7.  The  proximate  cause  of  seasickness  is  the  heap- 
ing of  the  brain  mass  upon  itself  by  centrifugal 
force,  and  subjecting  the  part  to  pressure  against 
the  bony  casement,  or  to  the  hurtful  centrifugal 
movements  of  the  cerebro-spinal  fluid,  which  also 
leave  parts  of  the  brain  exposed  to  injury.  Prefer- 
ence is  given  t<>  the  latter  view  |  L856,  Fonssagrives). 

This  is  a  further  stage  in  the  development  of  the 
mechanical  theory,  which  is  fast  approaching  an 
absurdity. 

s.  The  proximate  cause  is  hyperemia  of  the  spinal 
eord,  especially  in  those  segments  related  to  the 
stomach  and  muscles  concerned  in  vomiting,  induced 
directly  or  reflexly  by  the  irritating  movements  of 
the  brain,  spinal  cord,  abdominal  and  pelvic  viscera, 


I'KKVKNTI  VK    TRKAT.MKXT    OK    SKASICKNB8S.         L43 

and  by  jcj-ks  on  the  spina]  Ligaments.     The  invokm 
tary  muscles  aredisturbed  by  fche  unwonted  number 
of  impulses  transmitted  to  them   from  the  preter 
naturally  excited  spinal  cord  (1864,  Chapman). 

This  theory  marks  the  beginning  of  a  new  era. 
A  good  many  threads  of  truth  run  like  gold  through 
the  dark  web,  and  physiology  is  in  an  able  manner 
brought  to  the  aid  of  the  old  theories  of  small  con- 
cussions and  mechanical  irritations.  The  treatment 
by  means  of  the  spinal  ice-bag  does  not  seem  to  have 
increased  the  comfort  of  travellers. 

9.  It  seems  to  be  due  to  the  sudden  and  recurring- 
changes  of  the  relations  of  the  fluids  to  the  solids  of 
the  body  (1868,  Barker). 

10.  It  is  due  to  the  disordering  movements  of  the 
cerebro-spinal  fluid,  from  which  results  an  inter- 
mittent anaemia  and  a  certain  degree  of  commotion 
of  the  cerebral  mass.  Children  are  exempt  through 
expansibility  of  the  fontanelles  (1S6S,  Autric). 

It  does  not  seem  plausible  that  a  force  sufficient 
to  cause  the  fontanelles  to  bulge  would  not  compress 
the  very  yielding  blood  vessels  of  childhood,  and 
children  with  widely  open  fontanelles  are  not  always 
exempt. 

11.  It  is  due  to  the  continued  action  on  the  brain 
of  a  certain  set  of  sensations,  more  particularly  the 
sensation  of  want  of  support  (Carpenter,  Bain,  and 
(1872)  Pollard). 

This  is  a  development  of  the  very  shrewd  guess  of 
Gillchrist.  It  stands  at  the  beginning  of  new  views. 
The  mechanical  theories  do  not  seem  to  have  gone 
much  beyond  "  possibilities "  in  their  explanation 
of  the  symptoms.      Experiments,    observed  order 


Ill  DM  THK  NATUKE  AND 

of  sequences,  and  Logic  now  nun  on  a  flood  of 
light. 

L2.  Seasickness  is  a  functional  disease  <>!'  the  con* 
tral  nervous  system,  mainly  of  the  brain,  but  in  some 
instances  of  the  spinal  cord  also,  the  result  of  a  series 
of  mild  concussions  ( is^>.  Beard  . 

The  cause  is  inadequate,  and  functional  disease  of 
the  central  nervous  system  is  not  very  definite  or 
lucid.  The  preventive  treatment  by  bromization, 
however,  was  a  greal  advance  in  therapeutics. 

13.  Motion  produces  sickness  by  disturbing  the 
endolymph  in  the  semicircular  canals,  the  viscera  in 
the  abdomen,  and  possibly  the  brain  and  subarach- 
noid fluid  at  its  base  (  1881,  Irwin  |. 

14.  All  the  symptoms  of  seasickness  can  be  ex- 
plained by  paresis  of  the  sympathetic  (1887,  skin- 
ner). 

This  is  a  very  important  factor,  but  how  is  the 
paresis  induced  \  It  is  an  epiphenomenon,  and  an 
imp. trtanl  indication  in  t  he  drug  t  real ment. 

15.  Vertigo  and  vomiting  are  the  essential  symp- 
toms. The  movements  of  a  ship  in  a  storm,  par- 
ticularly its  quick  descent,  cause  movements  of  the 
cerebro-spirial  fluid,  and  cerebral  blood  is  displaced 
and  the  1  nain  subjected  to  shocks  and  the  cen  •helium 
to  commotion  ;  or  movements  of  the  abdominal 
visceraand  conl  factions  of  the  diaphragm,  with  their 
resulting  local  action  and  reflex  inhibitory  influ- 
ences I  lsvv.  Pampoukis). 

16.  The  symptoms  of  seasickness  are  those  of 
cerebral  anaemia.  The  uncommon  and  disordering 
movements  that  are  felt  derange  and  diminish  reflex 
muscular  tonicity  and  contraction,  which  maintain 


PREVENTIVE  TREATMENT   OF   SEASICKNESS.       L45 

equilibrium  and  regulate  the  return  venous  circula- 
tion. Then  results  a  muscular  relaxation,  of  which 
the  loss  of  equilibrium  is  the  sign  and  the  cerebral 
anaemia  the  consequence  (1890,  Rochet j. 

It  seems  that  too  great  prominence  is  given  to  loss 
or  diminution  of  reflex  muscular  tonicity.  Fatigue 
is  chiefly  central,  and  the  most  highly  endowed  and 
the  most  differentiated  tissue  is  the  first  to  become 
exhausted.  We  have  seen  that  in  the  production 
of  the  paresis  of  the  sympathetic  and  prostration 
central  fatigue  is  one  of  the  factors.  It  seems  that 
muscular  relaxation  would  have  to  be  pretty  well 
marked  before  there  could  be  much  interference 
with  the  return  venous  circulation.  And  vertigo  is 
present  when  the  pupil  is  contracted  under  exciting 
sensations  and  the  traveller  is  walking  in  the  dark. 
The  theory  makes  a  deferred  result  the  active  cause, 
but  withal  is  the  best  explanation  yet  given. 

There  are  varying  degrees  of  susceptibility  to  the 
disease.  We  have  seen  how  powerful  a  predis- 
posing cause  is  acute  dyspepsia.  The  anaemic,  the 
neurotic,  the  neurasthenic  yield  very  readily  to  it, 
as  do  all  who  have  weak  and  easily  excited  nerve 
centres.  Athletes  in  training  have  been  prostrated, 
while  delicate  women  were  laughing  at  their  dis- 
comfort. Infancy  and  old  age  are  more  exempt 
than  middle  life.  Individuals  subject  to  vaso-motor 
disturbances  are  predisposed  to  the  malady.  All  the 
symptoms  have  been  often  reproduced  on  land,  after 
the  lapse  of  months,  by  association  of  ideas. 

Seasickness  is  not  a  fatal  disease.  Deaths  have 
been  recorded  as  due  to  it,  but  in  these  cases  it  only 
caused  the  already  suspended  sword  to  fall.     Sea- 

10 


1  (i;  (  »\    THE    N  A  II"  UK    AND 

sickness  is  an  e\  il  ;  it  is  never  "  very  g I  at  times  *' 

(Burt «)in,  nor  "  salutary  "'  (Johnson).  All  the  good 
effects  of  sea  travel  are  obtained  without  it.  It  is 
a  dangerous  malady  when  organic  disease  of  the 
hear!  or  blood  vessels,  or  of  1 1 1  *  *  stomach,  or  of  the 
nervous  system,  or  of  t  he  lungs,  liable  to  be  at  tendril 
by  haemoptysis,  is  present,  [t  nearly  always  delays 
or  disorders  menstruation,  and,  asiswel]  known, 
has  often  terminated  pregnancy.  It  sometimes 
persists  for  a  variable  period  after  the  voyage,  and 
some  never  completely  recover  their  sense  ofequi 
librium  and  of  space. 

Bad  treatment  is  the  natural  sequence  of  false 
views  of  causation.  When  we  know  how  a  symp- 
tom or  disease  is  produced  theimanagement  becomes 
rational,  though  nol  always  efficient.  To  the  consid 
oration  <>f  the  preventive  treatment  a  few  practical 
suggestions  will  be  added  on  the  management  of  the 
attack. 

In  the  prevention  of  seasickness  we  work  along 
two  lines — the  removal  of  the  predisposing  causes  and 
the  diminution  of  the  action  of  the  exciting  ones. 
In  each  instance  we  strike  at  causation,  and  the 
effect  of  the  double  blow  is  commonly  satisfactory. 
My  attention  was  first  drawn  to  this  method  of 
prevention  by  the  comparative  immunity  from  sea- 
sickness of  patients  who  were  under  my  treat  ment, 
before  and  during  the  voyage,  for  someone  of  the 
many  disorders  and  diseases  of  nutrition.  So  far 
my  experience  with  the  method  has  not  been  very 
great,  only  a  few  more  than  one  hundred  cases  hav- 
ing been  managed  in  this  manner.  The  number  of 
cases  is  only  large  enough  to  suggest  rather  than 


PREVENTIVE    TREATMENT   <>K   SEASICKNESS.        L47 

establish  the  value  of  the  treatment.     But  if  it,  be 

iindcisl (I  that  more  than  half  of  these  travellers 

had  been  previously  so  sick  that  they  turned  with 
honor  from  the  repetition  of  the  voyage,  and  that 
more  than  three-fourths  of  tliem  completed  the  p;t 
sage  under  the  influence  of  my  method  without  the 
slightest  qualm,  and  subsequently,  when  neglecl 
rag  my  directions,  became  fearfully  ill,  it  may  be 
thought  advisable  to  state  the  method  to  the  profes- 
sion with  a  view  to  having  its  utility  thoroughly 
tested. 

The  treatment  as  directed  to  the  digestive  system 
has  one  important  object  in  view — to  diminish  the 
irritability  of  the  sensory-nerve  endings  of  the  mu- 
cous lining  of  the  alimentary  canal  by  keeping  the 
digestive  tube  functionally  active,  clean,  and  sweet, 
and  the  consequent  prevention  of  acute  dyspeptic 
attacks.  And  we  follow  up  the  advantage  thus 
gained  by  securing  active  elimination  and  perfect 
assimilation  and  disassimilation,  thus  strengthening 
and  saving  from  the  irritation  of  an  impure  blood 
the  nerve  centres,  whose  overexcitation  and  fatigue 
play  so  important  a  role  in  the  development  of  the 
malady.  In  a  few  words,  we  strive  to  promote  a 
high  degree  of  healthy  nutrition,  because  we  believe 
that  a  strong  man  is  best  prepared  to  resist  the 
encroachments  of  disease.  Good  nutrition  is  a  well- 
fitting  armor  that  turns  aside  many  a  deadly  blow. 
If  we  succeed  in  realizing  this  high  endeavor,  I  do 
not  believe  that  the  anaemic  stage  of  seasickness 
will  be  developed. 

Close  attention  to  the  hygiene  of  nutrition  will 
enable  us  to  get  the  vital  processes  on  a  physiologi- 


IIS  ON    THE    \  vn  RE    \M> 

cal  basis.  I  >nly  a  Eew  days  will  be  required  for  this 
purpose  if  there  be  but  slight  disorder  of  one  or 
moreof  the  nutritive  processes.  The  week  before 
sailing  is  commonly  one  of  excitement,  dissipation, 
ami  worry.  All  preparations  lor  the  voyage  should 
be  completed  several  days  before  going  aboard 
the  bowels  regulated  by  laxatives,  the  secretions 
righted  and  supplemented  if  requisite,  elimination 
keep  free,  and  a  plain,  easily  digested,  and  easily 
assimilated  diet  should  be  adopted.  In  a  general 
way  the  sweetsand  starches  should  be  limited,  and 
Lean  meats  made  the  staple  food.  But  the  age,  ac- 
tivity, peculiarities,  habits,  the  needs  of  general  nu- 
trition, the  capability  of  the  digestive  organs,  must 
all  be  taken  into  consideration  in  the  select  ion  of  the 
diet.  The  means  must  be  varied  to  suit  each  special 
ease,  for  individualization  is  the  secret  of  success. 
But  the  aim  is  simple  and  definite — to  secure  the 
perfect  digestion  and  assimilation  of  a  sufficient 
quantity  of  food  to  meet  the  requirements  of  nutri- 
tion. If  the  patient  gels  eight  hours  of  restful  sleep 
every  night,  and  feels  no  pain  or  discomfort  or 
drowsiness  after  meals  ;  if  there  is  no  flatulence  ;  if 
the  urine  contains  no  abnormal  coloring  matter  nor 
excess  of  phosphates,  urates,  or  uric  acid,  and  the 
stools  are  normal   -we  know  that  the  food  is  being 

digested,  absorbed,  and  assimilated  in  sufficient 
quantity,  if  there  be  no  loss  of  strength  to  meet  the 
demands  of  life,  and  that  the  excretory  products 
are  changed  into  their  simplest  and  most  soluble 
and  most  unirritating  forms.  Until  this  state  of 
nutrition  is  established  the  patient  is  not  prepared 
for  the  voyage.      The  same  simple  and  regular  and 


PREVENTIVE   TREATMENT   OF   SEASICKNESS,        I  I'.i 

temperate  way  of  Living  and  eating  tnusl   be  ob 
served  throughout  the  passage. 
When  there  is  a  serious  derangement  or  disea  e 

of  the  digestive;  system,  the  proper  treatment  nm-i 
be  instituted  to  secure  the  one  aim  of  healthynu 
trition.  How  this  can  be  undertaken  with  the 
greatest  hope  of  success  lias  been  outlined  by  me 
in  articles  published  in  the  New  York  Medical 
Journal. 

The  second  part  of  the  preventive  treatment  is 
intended  to  diminish  the  activity  of  the  exciting 
causes  until  the  organism  can  adapt  itself  to  the 
Hew  environment  and  become  inured  to  the  disor- 
dering sensations. 

During  the  first  forty-eight  hours  it  is  advisable 
to  remain  in  bed  and  sleep  as  much  as  possible. 
The  effort  to  maintain  equilibrium  is  diminished, 
"the  confusion  through,  the  sight  of  moving  objects 
is  limited,  the  life  of  relations  is  "  cabined  and  con- 
fined," consciousness  is  diminished  at  last.  Four 
light  meals  should  be  taken  a  day  and  very  little 
fluid  drunk.  The  danger  of  a  mechanical  hyper- 
emia of  the  nerve  centres,  by  excessive  muscular 
tonicity  forcing  the  blood  out  of  the  musculo-venous 
reservoir,  will  be  obviated.  The  only  drink  should 
be  a  single  cup  of  hot  water  with  each  meal. 

After  the  expiration  of  this  preliminary  period, 
during  which  the  action  of  the  exciting  cause  is 
weakened  and  the  organism  is  being  accustomed  to 
the  disordering  sensations,  the  time,  except  that 
which  is  regularly  given  to  sleep,  should  be  spent 
in  the  open  air  on  deck.  The  sensory  vertigo  which 
is  ever  ready  to  arise  into  consciousness  must  be  sup- 


L50  ON    mii:   \  LTURB    \m» 

planted  by  purposive  movements,  the  efficiency  of 
which  can  be  verified,  as  walking,  etc.,  and  by  men 
fcal  occupation  or  diversion.     It  is  well  known  thai 
intense  Tear  or  excitement   or  absorbing  thought 

will  dissipate  "the  bw dng  sickness  on  the  dismal 

sea."  The  vertiginous  sensation  is  driven  out  of 
consciousness  by  the  commanding  presence  of  a 
powerful  emotion,  feeling,  or  thought. 

A  widely  known  method  of  diminishing  the  ao; 
tion  of  the  exciting  cause  is  by  the  use  of  the  bro- 
mide <>t'  sodium,  which  must  be  pushed  to  its  full 
l>h\  siological  effects  and  the  influence  kept  up  dur- 
ing the  entire  voyage.  The  neuro-muscular  disor- 
der is  controlled,  and  sensory  perception,  both  peri- 
pheral and  central,  is  dulled.  The  drug  influences 
favorably  the  simple  vertigo,  prevents  the  develop- 
ment of  the  hypersemia,  but  it  intensifies  the  misery 
of  the  anaemic  form.  The  treatment  is  often  effi- 
cient, but  it  should  never  be  tried  except  on  the 
advice  and  under  the  supervision  of  a  physician. 
Seasickness  itself  is  not  so  harmful  as  may  be  bro- 
mi/ation.  The  large  doses  usually  upset  the  sto- 
mach, and  the  drug  irritates  all  the  organs  by  which 
it  is  eliminated.  The  bromides,  when  pushed  to  the 
point  of  poisoning,  often  exert  a  persistent  and  per- 
nicious influence  on  the  nervous  system. 

The  treatment  during  the  attack  is  quite  different 
in  the  anaemic  and  the  hyperaemic  varieties. 

When  hvpera'iiiia  is  present  the  influence  of  the 
exaggerated  reflex  muscular  tonicity  can  be  dimin- 
ished by  voluntary  muscular  movements,  which  re- 
quire muscular  relaxation  as  well  as  contraction  for 
their  performance.  The  vertical  position  is  an  ad- 
vantage.    A  hot  foot  bath  will  also  draw  the  blood 


PKEVENTIVE  TREATMENT  OP  SEASICKNESS.         I  5  1 

away  from  tlio  nerve  centres,  as  keeping  the  Eeet  in 
very  hot  water  for  somo  time  has  produced  syncope. 
A  very  powerful  effect  can  be  produced  by  placing 

the  hands  and  feet  in  hot  water  and  applying  Lee  to 
the  head  and  spine.  Counter-irritation  is  a  proce- 
dure of  questionable  utility.  Caffein  will  suppress 
the  sense  of  central  fatigue.  Antipyrin  or  bromide 
of  sodium  by  the  rectum  may  be  of  some  use 

In  the  ana3inic  stage  such  drugs  as  must  be  ab- 
sorbed to  produce  an  effect  should  be  given  hypo- 
dermically.  Atropin  is  the  best  drug  to  stimulate 
the  paretic  sympathetic,  but  nitroglycerin  must  be 
given  simultaneously  to  dilate  the  arterioles. 
Strychnin  and  the  natro-benzoate  of  caff  em  also 
meet  obvious  indications.  Ergotin,  on  account 
chiefly  of  its  action  on  the  urine,  is  also  valuable. 
The  judicious  use  and  combination  of  these  five 
remedies  will  meet  the  indications  from  the  side  of 
the  muscular,  nervous,  and  circulatory  systems. 
Whiskey  (and  food  also)  may  be  required  by  the  rec- 
tum. The  horizontal  position,  with  the  head  low, 
should  be  persistently  maintained.  The  vomiting 
will  also  be  favorably  influenced  by  the  preceding 
drugs.  Copious  draughts  of  hot  water,  to  wash  out 
and  soothe  the  stomach,  is  a  remedy  of  great  value. 
Frequently  repeated  and  small  doses  of  creosote, 
with  lime  water  and  an  infinitesimal  quantity  of 
ipecac,  may  be  effectual.  Oxalate  of  cerium,  in 
five-grain  doses  every  hour  for  three  or  four  ad- 
ministrations, is  another  good  remedy.  If  these 
preventive  precautions  and  remedies  fail,  the  pa- 
tient must  content  himself  until  he  can  again  get 
into  his  element,  the  place  where  he  was  created 
and  educated  to. live — on  land. 


COLUMBIA    UNIVERSITY   LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing,  as 
provided  by  the  library  rules  or  by  special  arrangement  with 
the  Librarian  in  charge. 

DATE   BORROWED 

DATE   DUE 

DATE   BORROWED 

DATE   DUE 

r  ppc 

nnTT 

m  pp'f 

"D"nt"^r  i '  y 

i.  i  -X       *-   * 

\  v  s  ...• ' 

^  *?  ■ 

-A.  \      * 

C28 (IO-53) 100M 

SOUTH  PROPERTY  «c8oi 

V37 
Van  Valzah  1892 

Chronic  disorders  of  the  digestive 
tube. 


SOUTH  PRO" 


T\CBot 
179*. 


I 


